HomeMy WebLinkAboutG-12-489 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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! JOBSITE ADDRESS I tik-ailec 4th OWNER'S NAME
OWNER ADDRESS y/H ✓/Yy7 f/�h f2�— ITEL 3(,pZ0,3? FAX
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TYPE _OCCUPANCY TYPE 'COMMERCIAL❑ `r -' - EDUCATIONAL ' RESIDENTIAL I
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CLEARLY NEW:❑ RENOVATION:Li REPLACEMENT: PLANS SUBMITTED: YES N0O
` APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER Me
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Vl` BOOSTER 51..A.3.,____{._
COOK STOVE
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INFRARED LABORATORY
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INFRARE HE COCKSmime 1
MAKEUP AIR UNIT ali
OVEN 0111101.111a11.1111a1MOMPINIONSIONIS MO
POOL HEATER11111.11.11111.1111•1110111111111111001111111110101.111111101111011111111111111111
ROOM/SPACE HEATER111111101110.111111111aliaailliall
ROOF TOP UNITr • - S I jSS ] JS ISS J 'IS
UNIT HEATER ' S :^
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WATER HEATER ' MINC _ a
OTHER _ - 111.111111011101111119111111 1110_ 1111111101111J
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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 El NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
—
LIABILITY INSURANCE POLICY [] OTHER TYPE INDEMNITY ❑ BOND ❑
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.
CHECONE ONLY: 0 , ER ' AG-
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have submitted or entered regarding this,•plication are true an• - urate tot•: ••- of • edg=
and that all plumbing work and installations performed under the permit Issued for this applica on will be In compllance •th all Pe t • is• the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW I LICENSE#17S8 S NATURE
MP 0' MGFF❑ JP❑ JGF❑ LPG'El �', CORPORATION❑+ # 3281C PARTNERSHIP EX LLC❑# '`
COMPANY NAME: E.F.WINSLOW PLUMING&HEATING' I ADDRESS 8 REARDON CIRCLE' 1
CITY SOUTH YARMOUTH I STATE MA ZIP 02664 TEL 508-394-7778
FAX 508-394-8256 CELL N/A EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM t
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
y
•
•