HomeMy WebLinkAboutG-13-363 ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK •
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CLEARLY NEM._J RENOVATION: _J REPLACEMENT: ,,ePLANS SUBMITTED: YES--J N��Y
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INSURANCE COVERAGE
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.C ) 42E 6E Lill(Ii l
71
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW goy (� D to- 1100
LIABILITY INSURANCE POLICY ,!_f OTHER TYPE INDEMNITY -J ND 5 Z L
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required ty ChaptaU1f3010G311BEVTQ i/_
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Massachusetts General Laws,and that my signature on this permit application waives this requirement. By - �T
CHECK r• 'E ONLY: OWN R A 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 a - .to the •est of my o -dge
and that all plumbing work and installations performed under the permit Issued for this application will be In compliance wi h: 'e • t pr• ision • e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME STEPHEN A WINSLOW _i LICENSE#.12298.-_) SIGNATURE .
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MP !: MGF_J JP J JGF___I, LPGI _J CORPORATION;J# 3281 �_1 PARTNERSHIP J#_,,.___._, __,J LLC ._J#
COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING Ulf ADDRESS.8 REARDON CIRCLE_
CITY SOUTH YARMOUTH_ I STATE _MA j ZIP 02664 _._-.;TEL 508-394-7778 _ __ __
FAX.508-394-8256 I CELL_. , ________ _I EMAIL ACOOUNTSPAYABLE@EFWINSLOW.COM _________ _ ______ __J
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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 0 0
FEE $ PERMIT#
• PLAN REVIEW NOTES
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