HomeMy WebLinkAboutG-14-584 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CLEARLY NEW:.J RENOVATION: _J REPLACEMENT:•_I PLANS SUBMITTED: YES NO-I` ---
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INSURANCE-COVERAGE 11
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch�"•142 �r�;`ib ,(,ES I I i
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW I U -. ' ` I
LIABILITY INSURANCE POLICY +J OTHER TYPE INDEMNITY -J 9 ND I_:i - i"13 J
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required I Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement. CU; CJ�':'T
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• CHECK ON r• • •WNE•• J AGE
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 - • accur to to = best of my vAedge
and that all plumbing work and Installations performed under the permit Issued for this application will be in compliance .II Pe ine•t provisio •f the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME STEPHEN A WINSLOW LICENSE# 12298- SIGNATURE
MP _C1 MGF _..i JP .L JGF - ; LPGI __J CORPORATION . I# 9281. .,,___) PARTNERSHIP _J# .,. LLC -__I# _ -,,,
COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING COfi ADDRESS 8 REARDON CIRCLE_
CITY SOUTH YARMOUTH STATE MA ZIP 02664 ;TEL 508-394-7778
FAX 50&3948256 _..I CELL. _ . _.___-__ (EMAIL ACCOUNTSPAYABLE EFWINSLOW.COM .
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY " FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
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