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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
s giros 4 `' O /./I' , f PERMIT# i' / -ir-al l ;
_..1=1= .,'Y CITY f'�. 5/�--1 MA DATE
JOBSITEADDRESS ` ) Gf 1= IOWNER'SNAME: -De Co .
GOWNERADDRESS ¶,55_ 3w F w _ m, _ I TEy 5O1, Z�}� / FAX i,,__�____'a
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TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL• RESIDENTIAL V
PRINT
CLEARLY •
NEW:Q RENOVATION:0 REPLACEMENT:7f PLANS SUBMITTED: YES r j NOD , .
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 6 6 7 8 9 19 11 12 13 14
BOILER I t=f "`„.._te t 2;5,^J e__I^.�J D 1=
BOOSTER C. ,.,.,_i _�:_..._I a...1_..__i;.,...,= }12 �= _s
CONVERSION BURNER C- .�,L. ..jJ ..._J(.._._.J=1 .__.J .__._J'L_1:_n:11D_.___.J.._J --.-_ I
COOK STOVE n.tet,_.,___,'_.__,J .�' :.. ..._.._..1 -_-_- .__.S'...,.._.J 1_,,..P.1._. ..1 r
DIRECT VENT HEATER ..:1,..._..,:2-..L---1--c......!.-.,_--I._._J.._....a_... --I.--1,.-.1 W
DRYER ,,..�... �
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FIREPLACE ' t L_J'- --I--i ---1 .-.-1.- :L....„J I'"'----,
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FRYOLATOR —t ____1 Ir.J_.._.J` f- _r_./.., -- -74. -r--�
FURNACE 1^• --. - '---_.i.-,--,---4. —rt 1----j.J..»_.;J.-r -I - .1..y.•,
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GENERATOR ' ' ' I ` '
GRILLE , .,..,. '.....,...:..r.-._.,I..m,.....1 z:• ^-_ ^^v.J.,..m...i___...71-,--.......,...1.........!:._._.._J..—.+
INFRARED HEATER ........'---e-- _..J—_1 ,.....„_;.._._...i ._,-_J . .......4 _r .M.......1..-_-4_ .,1...-,.:
LABORATORY COCKS I ,,�I ,. _ _ ____ __ J . - .J -.,:-r..1.-•-,-.-
MAKEUP AIR UNIT ......__i..,...;.r•........t� ..1'.._ 1•.- J 1- .: v I-„-•ra ----1-�-..I.• _ ;
OVEN __._..,-. .r.. '`-- ::,__...., . ..-4 -• J -:s-;-......_ t1. __. :='1-^
POOL HEATER _.�..I-._....J_.__i -_ .__a.— —--_.-.I ---I---r':-1-._.J 1 .—
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_1 r - �_I I. ,. -_._J 1 __. :_ .., .J ,.I. - ,-...:LJ
ROOM 1 SPACE HEATER , _.-�__...�..J
ROOF TOP UNIT ____1, I ---I •-•-•-•a I,,.F�.�„1•---J
TEST - -(-I___.. _—I'-- ..'. _.._i ___ _
• T�4EATfsR _ ..- • - :.!!---J�J __-.3._.i -._.' .. _ILI)..a1•__J—
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BUILDING --
. me —.-. 1 INSURANCE COVERAGE
I have a current tiability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [+,)NO J
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW •w 1 '
LIABILITY INSURANCEPOLICY 21 OTHER TYPE INDEMNITY .J BOND [3
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 ONE ON • NER ..J AGENT C
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 end ac to to the best o my knowledge'
and that all plumbing work and Installations performed under the permit Issued for this application will be In compliance with a a ant pr•-slon of the ®
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
L._
PLUMBER-GASFITTERNAME STEPHENA.WINSLOW LICENSE#•12298 SIGNATU'
MPI:J MG r.:) JP.j JGF;_„( LPGID CORPORATION[#'32810 .LiPARTNERSHIPD# LW_a#', i
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3OMPANY NAME E.F.Winslow Plumbing&Heatinq Co.z.Inc. I ADDRESS'.8 REARDON CIRCLE
3iTY :SOUTH YARMOUTH I STATE: MA 'i ZIP;02884 1TEL,508394-7778
;Ai 508-394-8258 10ELLIN!A (EM,AIL accountsra able•refwinslow.com
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