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�-- . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
• . CITY '• /A)tm?LNk) I MA DATE' l g . PERMIT#C)'Z
-- JOBSITE ADDRESS[Z3{r(/I�r/1d))I12s' kterA11 dr 1Co 1I OWNER'S NAME r SO
B L_, I
f G OWNERADDRESS r�2 1"^ lmv ' -t I * (TEI SO 797- 1FAXr . I ,.
PRINT OCCUPANCY TYPE - COMMERCIAL[, EDDUUC IONAL❑ _ , RESIDENTIAL /1st _
CLEARLY NEW:0 RENOVATION:U REPLACEMENT: PLANS SUBMITTED: YES L] N• .
Ne APPLIANCES 1 FLOORS-. 66M 1 2 3 4 5 6, 7 8 9 10 11 12 13 14
BOILER I j 1 ' ' ;
CONVERSIONN BOOSTER BURNER Sr�[ -.[�._Jf'rl inir al
ni • • INflflSfl.L1fl1.K STOVE 1111 J 1
FRYOLATOR al$1",GENERATOR � 1
GRILLE �'' 1 3
INFRARED HEATER 1'
I J 1
MAKEUP AIR UNIT
LABORATORY COCKS 1• II
1
OVEN , II _ II q _I
POOL HEATER 1 I - I 1
ROOM ISPACE HEATER I 1 r
i ROOF TOP UNIT ,r i ii i ..:::._ i i
TEST I THEATER . I .. . I.
UNVENTED ROOM HEATER i
J1.. t ._.1.. __ m . .: . .. ,
WATER HEATER 1 1
OTHER i.--. ., I I R
_,_ __I --I_- '
__I I�J __..J ___1 _____I 1_1 _J-I ____,1 _t__-1
INSURANCE COVERAGE
I have a current liability 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 [11 2 OTHER TYPE INDEMNITY ';,,,J BOND I.
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.
CHE• ONEONLY 0 •NER
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are t •- and a!irate to . best o owledge
and that all plumbing work and Installations performed under the permit Issued for this app(cation will be in compll- 1 ,wi 1 =II Pert en • • I • 4 the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r
PLUMBER-GASFITTER NAME i STEPHEN A.WINSLOW LICENSE ' tib SI a`ATURE '
MP E MGF 1,..1 JP 1 JGF J LPG(L COR -- _i ..__ ..
„_J � f � � CORPORATION IPARTNERSHIP�_J# ' ILLC.J#. I
COMPANY . :
NAME E,F.WINSLOW PLUMING&HEATING I ADDRESS 18 REARDON CIRCLE I I'
CITY SOUTH YARMOUTH J STATE r MA I ZIP 102664 1TEL1508-394-7778 I
FAX150&394-8256 I CELL:—N IEMAILI ACCOUNTSPAYABLE@EFWINSLOW.COM 1
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
•Yes No
• THIS APPLICATION SERVES AS THE PERMIT 0 0
•
FEE S PERMIT ffi
PLAN REVIEW NOTES
•
•
•
A.
•
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