HomeMy WebLinkAboutG-14-329 �� •
MASSACHUSETTSp� UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING/ (/ WORK
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JOBSITE ADDRESS �y7 G{ 4,/ �1ee i0d lOWNER'SNAME 922.4_ ///�c'Ic _j
OWNER ADDRESS tilLYc*-gr)^/^17 ITEL;Wt775 1FAX J
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NEW:_J RENOVATION: ._) REPLACEMEN71 PLANS SUBMITTED: YES _J NOj6
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ENT INSURANCE COVERAGE
I a tc 1 "•.ikJ T _ .nc 'olicy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Li] NO ...1
I I • - ED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
'LIABILITY INSURANCE POLICY +J OTHER TYPE INDEMNITY .; BOND I__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.
CHECKO • ' : OWNER AGENT ..
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 and . urs :to the be- of my kn• :'ge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance wit . •ertinent:revision o
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /4—
PLUMBER-GASFITTER NAME STEPHEN A WINSLOW ; LICENSE# 12298 I SIGNACURE
MP .Ci MGF __i JP _ JGF _ LPG] _- I CORPORATION I# 3281. . _ I PARTNERSHIP __1# .. . I LLC __J#
COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING COfj ADDRESS 8 REARDON CIRCLE_
CITY SOUTH YARMOUTH ' STATE MA ZIP 02664 -.._,.'TEL 508-394-7778
FAX..508-3948256 - 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 ❑ ❑ _
FEE: S PERMIT#
PLAN REVIEW NOTES
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