HomeMy WebLinkAboutG-12-704 er ..A
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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INSURANCE COVERAGE
I have a currentJiability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES U NO J
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POUCY OTHER TYPE INDEMNITY [ BOND LI-
OWNER'S
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 0 ONLY:. OWNE' ' 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 We and - a to the ', t of my -dge
and that all plumbing work and Installations performed under the permit Issued for this applicatio will be In compliance ' II Pedln ./ slon .e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER•GASFITTER NAME I STEPHEN A.WINSLOW II LICENSE#112298 SIG'ATURE
MPLa MOF L.1 JP LJ JGF„ LPG!LI CORPORATION u#3281C I PARTNERSHIP sJ# LLC J#r _ I
COMPANY NAME]E.F.WINSLOW PLUMING&HEATING I ADDRESS 18 REARDON CIRCLE
CITY SOUTH YARMOUTH ' - I STATE�1ZIP 02664 ITELI508-394-7778 I
FAX(508.394-8256 CELLI N/A (EMAIL ACCO UNTSPAYABLE@EFWINSLOW.COM 1
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ROUGH GAS INSPECTION NOTES ;,
THIS PAGE FOR INSPECTOR USE ONLY
FINAL INSPECTION NOTES
This i No
SERVES AS THE PERMIT YO
FEE Ste_ PERMIT
PLANREVIEW NOTES
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