HomeMy WebLinkAboutG-14-217 ___ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CLEARLY ..---NEW:-_J RENOVATION: _J REPLACEMENT: PLANS SUBMITTED: YES_j NO4J,?
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Butt-DING 0&12r___-- INSURANCE COVERAGE
I ha • a • •.• urance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Li NO .- i
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY .4_1 OTHER TYPE INDEMNITY ..1 BOND 1:_;. •
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 ON • LY: OWNER _1 AGENT -_i /
SIGNATURE OF OWNER OR AGENT r /.
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accura'the be of my kno Ffr
and that ell plumbing work and installations performed under the permit Issued for this application be in compliance with a : i -n 'revision of
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
-- PLUMBER-GASFITTER NAME STEPHEN A WINSLOW ; LICENSE# 12298, J SIGNATURE
MP .+i MGF __i JP _ JGF JGF __ LPGI _J CORPORATION _ I# 3281.__. _J PARTNERSHIP J#_. J LLC .J#
COMPANY NAME: E.F.WINSLOW PLUMBING d HEATING COQ ADDRESS 8 REARDON CIRCLE_ __ •
CITY SOUTH YARMOUTH STATE MA ;ZIP 02664 'TEL 508.394.7778
FAX 508-394-8256 1 CELL -,,,- __ IEMAIL ACCOUNTSPAYABLE EFWINSLOW.COM _; _____ I
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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 ❑ 0
FEE $ PERMIT#
PLAN REVIEW NOTES
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