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__ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
mSN9®_A at c CITY )442/0,0-9721 I MA DATE[/ 5- /�-PERMIT#CII-- - 1/66
e� [G JOBSITE ADDRESS 7 a',1Dk)57-C/973---4N71ER'SNAME �.T�CE FIj�S�/
9 OWNER ADDRESS r,q & e..r £4 FeavitC4 , o of S TELro 83"-9QiFAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL E] EDUCATIONAL RESIDENTIAL V. !
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:( . PLANS SUBMITTED: YES❑ NO❑
Q APPLIANCES? FLOORS-. BSM 1 2 3 4 5 6 7 8 • 11 11 12 13 14
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CONVERSION BURNER J � I�11'� J �1161
COOK STOVE Jul . taw_I4 1 ,�' �i�
DIRECT VENT HEATER l —ii — i J J i
DRYER I ,fji— --J i -BU LOIN ti DEP! I
FIREPLACE J Jae JI J .�_. „_,_[
FRYOLATOR
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LABORATORY COCKS
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POOL HEATER _ J
ROOM/SPACE HEATERlillillial.11111,111111111111113111111.11211111.111
ROOF TOP UNIT 011111J0111111J910.111J11011111111111. 99111111111.1V0J111.
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UNVENTED ROOM HEATER _ _ .J' J _ '
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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 []NO Li
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY ❑ BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee floes 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.
CHEC ONLY: 011'ER AGENT r
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 d wear e to the .•- of my k l -edge
and that all plumbing work and Installations performed under the permit issued for this application II be In compliance `th I Pertin' t . • ision • the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW I LICENSE# 12298 I SIGNATURE
MPD MGF❑ JP❑ JGF❑ LPGI❑ ' CORPORATION Q# 3281C , PARTNERSHIP pit 1 LLC❑# 1 .
COMPANY NAME: E.F.WINSLOW PLUMING&HEATING ADDRESS 8 REARDON CIRCLE ' '
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778
FAX 508-394-8256 CELL N/A EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM
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ROUGH INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
I-31—j2 VA MP+'^,��h , Yes o
6-446 et - keE THIS APPLICATION SERVES AS THE PERMIT El
1� FEE: S PERMIT#S T 12- q44.
PLAN REVIEW NOTES
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