HomeMy WebLinkAboutG-12-490 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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OCCUPANCY TYPE COMMERCIAL❑ , . 1 EDUCATIONAL
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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 Q.NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY ❑ 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.
CHEC • 'E ONLY: ' 6 R ❑ T ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this ..plication are true-•d a urat. to the be . y knowledge
and that all plumbing work and Installations performed under the permit Issued for this applicet'.n will be in compllanc; 'th al •- inent , . Ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW I LICENSE#x12298 SIGNATURE
MP 0 MGF c:3; JP❑ JGFDi1::] ��
LPGI CORPORATION❑# 3281C PARTNERSHIP❑#I (LLC®#
COMPANY NAME: E.F.WINSLOW PLUMING&HEATING (ADDRESS 8 REARDON CIRCLE'
CITY ' SOUTH YARMOUTH ( STATE MA ZIP 02664' TEL 508-394.7778: 1
FAX 508-394-8256 I CELL N/A EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM j
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
gall- an 1--/z/l- 3/// Yes No CP
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: S PERMIT A I
PLAN REVIEW NOTES •
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