HomeMy WebLinkAboutG-13-194 .3tt alsig-I
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
�I ,' CITY uus_u 1 + t MA DATE q 113 L2ULZ_--J PERMIT# rt'/J- / ?
J9BSITE ADDRESS cal LO F\--11 4c tromp ¶OWNER'S NAME 11)1MI?I
V \ OWNER ADDRESS ' 5601TEL 55bt• 'fV %c'j.5 IFAX _J
YPE O
OCCUPANCY TYPE COMMERCIAL;] EDUCATIONAL _1 , - RESIDENTIAL b+"
PRINT EW.J . RENOVATION: J REPLACEMENT: PLANS SUBMITTED:YES J NO _-
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LPPLIANCES1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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DIRECT VENT HEATER IIIMEMMEEMS j=t111111
FRY• • •'GRILLE • I:IIIiU!1ItJ
INFRARED HEATERj01111I1111•11 11 1111111_
LABORATORY COCKS 11111111SPIII1 1Mfl♦I
MAKEUP AIR UNIT I5 1 f 5 ] 1a11J]. _.1111
OVEN ) _ 1
POOL HEATER ' I
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ROOM/SPACE HEATER I
ROOF TOP UNIT
TEUNIT HEATER J.1111.1.11101=` - 1 ME_ - —1
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UNVENTED ROOMHEATER . _._i__i___i_-_I____I
WATER HEATER _._..i— J_..I _ J ___ __I__J __ ..1. . __J__ 1 -_.,_l
OTHER I ___,.1 I _ J ____J J ,_:_ . J __ _I J ___._1 J_.____,1 __ .1
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1.J NO -.I
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Ci OTHER TYPE INDEMNITY J BOND IJ
OWNER'S INSURANCE WAIVER:.I am aware that the licensee does not have the insurance coverage required by Chapter o he
Massachusetts General Laws,and that my signature on this permit application waives this requireme
CHE ONE ONLY: OWNER J AGES J
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application are true an. :• rat, to the'est of my • edge
and that all plumbing work and Installations performed under the permit Issued for this application will be In compliance with . -satin nt p .vision• the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ��
PLUMBER-GASFITTER NAME STEPHEN A WINSLOW I LICENSE# 1 _2_1__;; SIGN.TURE
MP ii MGF _.j JP;J JGF_j LPGI J CORPORATION'J __# 3281 1 PARTNERSHIP .2#____ .__.J LLC i#
COMPANY NAME E.F.WINSLOW PLUMBING&HEATING CO ADDRESS 8 REARDON CIRCLE i " 'i
CITY SOUTH yARMOUTH , I STATE Mk ;ZIP 02664 _ 'TEL 508-394.7778 _T -` '
FAX 508-394-8256 J CELL . IEMAIL ACC OUNTSPAYABLE@EFWINSLOWAOM _�T _
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE $ PERMIT
PLAN REVIEW NOTES
7