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HomeMy WebLinkAboutG-13-570 $ 66P0 vo. 6kt, 0- _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK • =`11= cm/ PpR Mo 07-1-1I MA DATE I, - /21-PERMITS/I &/3 -576 JOBSITEADDRESS 1s9 /1fR74S — 1OWNEER'SNAME fl A - W rI • IG OWNER ADDRESS IF-ri'��0---- - �TE��•� FAXI— •TOR �nuT-- OCCUPANCY TYPE COMMECIALQ EDUCATIONAL [ RESIDE CLEARLY NEW:L..] RENOVATION:Q REPLACEMENT* PLANS SUBMITTED: YES U NO i. APPLIANCES 1 FLOORS-, BSM UM 2 ©0 5 6 7 8 a io m®m 14 BOILER MIN nal 11111111,111S al MN11t411#111;81111111i.111mon INN ammimom BOOSTER NM S1 i'iIIIIN.0111111S Ms MINI MI MN a Si CONVERSION BURNER .11111.N,;noingi,a a a a,a>•,a i a a Sill COOK STOVE .: 151. !IIIIIII NM 151 ri,a•I BIM 1111•I,111111111,SIN 1=11 Its ltd no so DIRECT VENT HEATER NIS,N;iriSI,a,a;;5,_i5,nit o ao,ma',N DRYER ' i•;laillISi1IIIIII,MIttKK11 sLN11INN;,NM II N MIN1Urilfi FIREPLACE MI In Ina Si:a:StS sin a,i n a a FRYOLATOR 11111111111111111111118111,INS$1111111,111.111111111a Olt't1111111IIIIII 'NMI FURNACE • l alaliallikillill:M:1111,111118 MINI MN SI,la 5.5 5'S GENERATOR N 11111111i;alXIII:MIN MIN'NM 11111.;5..MKS M,lIIII SIS. GRILLE N am Sate,nj a,ails,a ow n n ai 1 INFRARED HEATER M. a11.1 in nil 111101011.SW M M in MR ill • LABORATORY COCKS irr.1.rssF-.11S a;MIR.•1i5..Sal INII'S. MAKEUP AIR UNIT ININ,MI.NE'>•r:,s S S NM MI NM NM SSW SS Si OVEN 5_1MK,RI IIIIIII M;NMI.I•;o,is:isa.Iit55 POOL HEATER M NIS,,MK,ai:r all NS 11111111111111 MNIIIIIIII.MM. ROOM!SPACE HEATER N:Ma111111:5 5 MOM 55 5i!gillo INE o sis ROOF TOP UNIT ,M.1111,1111i M;S Mt MN stni 5ia 5:a'Kiri TEST 5I5:5i 5 11111111 MINI BM so an as SS MINI IMO MINI UNIT HEATER- . MINI MIR,M,!•'NM5Mill MINI::n 51 5:51 UNVENTED ROOM HEATER M,X IMO MI M NMI S,r MI,MI N t B:5i WATER. : : __--- -- 5.nil:INN MINI MI M,MI 5 NM III=,MINI r IMII IIINI MEI OTHER, no;Ina um in no a no is�! NS SE 11111111,11.111 alai"!IIIIIIIIIIIM,MEL MEI MAIM Ma MINI 1111.1111.NE MN MO INS 01.1111.1 PIS OM am sir a sr IN n.u.r.iwrrrr_, . ii,a a l'S Mika a:;o a a Iii INSURANCE COVERAGE I have a current Jlabiliw Insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 YES LI NO J I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 12 OTHER TYPE INDEMNITY 0 BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my Signature on this permit application waives this requirement. CHECK 0 : ' Y:. • ER J AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information have submi •or enters• regarding application are true• •-•: o,. 'r and that as plumbing work and Installations performed under the permit Issued for this application will • compliance w1 ' ;I,;, // moi Massachusetts State Plumbing Coda and Chapter 142 of the General Lan. PLUMBER•GASFITTER NAME I STEPHEN A.WINSLOW I LICENSE# 12298 SIGNATURE MPJ MGF I:3 JP L JGF`.J LPG!D CORPORATION u#(3281C 1 PARTNERSHIP:,••.I# 1 LLC J#� ' COMPANY NAME:(E,F.WINSLOW PLUMING d HEATING I ADDRESS I 8 REARDON CIRCLE CITY •SOUTH YARMOUTH • .-. — 1 STATE MA ZIP 025641TEL 1508.394-7778 --- . . 1 FAX 508.394-8256 CELL N/A IEMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM ' ' I I F — I • DEC 4012 _�fK . L ` ROUGH GAS IN +C t Non THIS PAGE FOR INSPECTOR USE NLy D A aT1ONSERVESAs nroa 0 0 FEE. $�� PERIVff$ - w xcam • — - I — --- • - .. 1 • I ' I . I