HomeMy WebLinkAboutG-12-396 1Z,, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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I. JOBSITEADDRESS 71/ kevrt— 44, IOWNER'SNAME JCEU/i.) 0/IOLST I
GOWNER ADDRESS S4/NE YA/InJIVFWPDtr ITEL SDi;-363--q/fl (FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL r4,�
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�` CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:I PLANS SUBMITTED: YES N a
` BBOILER OILETERES7 FLOORS BSM 11 1 1 II 2 ,I5 Ji 6 7 8ii1—I •�i �is 153l4
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CONVERSION BURNER i_ J1JL__JI_____II____J 1___,.k• k1 —JOIN
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COOK STOVE _ii .'�J� -'_' _J �r
DIRECT VENT HEATER �l I_IN 1�IH
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UNVENTED ROOM HEATERr f JP , ilMig
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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 Q 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 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.
CHECONEONL . OWNE: AGENT
SIGNATURE OF OWNER OR AGENT
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I hereby certify that all of the details and information I have submitted or entered regarding this application are t : •nd accuy e to the b •f my k • -dge
and that all plumbing work and Installations performed under the permit Issued for this application will be In complian : • I .II Perlman •••v.on , I e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE
MP 0 MGF❑ JP❑ JGF D LPGI❑ CORPORATION D# 3281C PARTNERSHIP❑# 1 LLC❑#
COMPANY NAME: E.F.WINSLOW PLUMING&HEATING I ADDRESS 8 REARDON CIRCLE I
CITY SOUTH YARMOUTH I STATE MA ZIP 02664 ITEL 508-394-7778 I
FAX 508-394-8256 CELL WA EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM I
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES