HomeMy WebLinkAboutG-13-234 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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O� JOBSITE ADDRESS J� W1Y1PA1UO�d Prl (OWNER'S TAM�$�000
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TYPE OR OCCUPANCY TYPECOMMERCIAL,J, EDAL
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CLEARLY: NEW:J ,RENOVATION: ._J REPLACEMENT: L ' PLANS SUBMITTED. YES_J NO_J
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INSURANCE COVERAGE
-+ 'v have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES u NO
t I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY •+J OTHER TYPE INDEMNITY J BOND 1_J
OWNER'S INSURANCE WAIVER:]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 • ONLY: OWNE: _ J A
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 7. =to the •-st of owledge
and that all plumbing work and Installations performed under the permit Issued for this applicationell be in compliance wit t eAin t• 'Aar�f of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Cc
PLUMBER-GASFITTER NAME STEPHEN A WINSLOW i LICENSE# 12298 _J SIGN•TURE
MP !.i MGF JP.-; I JOE.J LPG! J CORPORATION;__I# 3281 _______j PARTNERSHIP_i# j LLC ...J# _
COMPANY NAME. E.F.WINSLOW PLUMBING&HEATING COA ADDRESS.8 REARDON CIRCLE
CITY SOUTH YARMOUTH I STATE MA, j1 ZIP 02664 'TEL 508-3944778
FAX 508-394-8256 J CELL , _ IEMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM
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ROUGH PLUMBING INSPECTION NOTES
BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No -
THIS APPLICATION SERVES AS THE PERMIT ❑ 0
FEE $ PERMIT#
PLAN REVIEW NOTES
Y