HomeMy WebLinkAboutBLDG-15-001437 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
ns yniall ula____CSQO_l_l l_I MA DATE q-JJL/VL PERMIT# f`'Ob•IS�-OO��7
N1_ CITY p f
JOBSITE ADDRESS„ILA,1LerniG .�'P !OWNERS NAME ..,_.C,�rC?CLI1 -a— ,LUL�.IU.J
GOWNER ADDRESS ,. ,./ ,g) . _ _. JTEL5ds _9=oc3L.1FAX ._._I
TYPE OR OCCUPANCY TYPE COMMERCIAL L J EDUCATIONAL UU RESIDENTIAL.1,),/—
PRINT
CLEARLY NEW: _I RENOVATION: ....I REPLACEMENT:; PLANS SUBMITTED: YES,•., NO +,1
APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 -
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER I
DRYER I 1 [
FIREPLACE ! !
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT _ -
OVEN I _.
POOL HEATER ...,..._ __ ....,.,. _' . _ ___.._J ___I ..-__t __ . . _
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER !
UNVENTED ROOM HEATER
WATER HEATER '
-
!
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I%J NO __I
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ._L•I OTHER TYPE INDEMNITY V BOND Li
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.
CHECK r L .I • OWNE• __I' AG: _I
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 a • ura , to - •=-t of m •wledge
and that all plumbing work and installations performed under the permit issued for this application 11 be in compliance wit -.1 •ertin•nt provision • the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW J LICENSE# 12298 SIGN:TURE i'
MP ,42j MGF .j JP __.1 JGF J LPG! J CORPORATION J# 3281C__ PARTNERSHIP„..J#�_., I LLC ,w.)#m • .:'
COMPANY NAME: EF WINSLOW PLUMBING&HEATING . ._J ADDRESS 8 REARDON CIRCLE I
CITY SOUTH YARMOUTH — I STATE MAJ ZIP 02664 JTEL 508-394-7778 I
FAX 508-394-8256 J CELL N/A _EMAIL accountspayabletdefwinslowcom ii
L12 , I_
NI `�6 `� ' so .� wo, 3g3G%
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT#
PLAN REVIEW NOTES