HomeMy WebLinkAboutP-12-599 C-Q SJ, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK • • ,
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rJ >— Pitt`=CL • I Y NEW:❑ RENOVATION:0 REPLACEMENT:Er PLANS SUBMITTED: YES 0 NOEr
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ' - • 1. <':•
LIABIUTY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND❑
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
CH K ONE ONLY: 0 'ER ■ A W
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are • :and -• rate to th best of -dge
and that all plumbing work and installations performed under the permit Issued for this application will be in compli• t= ail Pe • e• • • • the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME STEPHEN A.WINSLOW ' 1LICENSE# 12298 SIGNATURE
MPD JP . CORPORATIONQ# 3281C IPARTNERSHIP❑# LLC❑#
COMPANY NAME E.F.WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778
FAX 508-394-8256 CELL WA EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT#
PLAN REVIEW NOTES
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