HomeMy WebLinkAboutG-13-593 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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__02 D F MA DATE] .-16 Id— PERMIT ft 22/38 _
JOBSITEADDRESS;/{/1&n /Ybic gal (OWNER'S NAME ! n j
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TYPE ORJ .EDUCATIONAL J RESIDENTIAL - ' '
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NEW:J -RENOVATION:'_) REPLACEMENT:L - PLANS SUBMITTED: YES J N
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DIRECT VENT HEATER I � . _
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INFRARED HEATER
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' INSURANCE COVERAGE
I have a currentliability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES IJ+ NO _.i
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY.INSURANCE POLICY 2.1 OTHER TYPE INDEMNITY .-J BOND 1_.i
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 a ONLY: •WNER J 'GENT _/
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application ere true an• - urat to the
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and that all plumbing work and Installations performed under the permit Issued for this application will be in compliance w
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Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME STEPHEN A WINSLOW _ . 1 LICENSE# 1229: _.' SIGNA FE
MP +J MGF J JP J JGF J LPGI -.: CORPORATION.A tt 3281,_—_j PARTNERSHIP J# --, „I LLC ___J#-___
COMPANY NAME: E_F.WINSLOW PLUMBING&HEATING COQ ADDRESS 8 REARDON CIRCLE _ '
CITY SOUTH YARMOUTH I ; STATE MA ,ZIP 02664 _ ,.,'TEL 508.394.7778 —__... _..
FAX 508-394-8258_]CELL , . I EMAIL ACCOUNTSPAYABLE@EFWINSLOWA! _ J
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