HomeMy WebLinkAboutG-12-397 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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PRINT OCCUPANCY TYPE COMMERCIAL❑ '
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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 Di NO Li
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY a 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. f
CHEC ' ONLY: OWN . fr 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 t - -nd ac .rate tot . • st of my ow-dge
and that all plumbing work and installations performed under the permit Issued for this applicati•n will be In complifi all Pe . • e
Massachusetts State Plumbing C
PLUMBER-GASFITTER NAMESTEPHEN AtGeneral Laws.
WINSLOW I LICENSE 41229: 1 SI-NATURE
MPD MGF❑ JP❑ JGF❑ LPGI p CORPORATION Q# 3281C PARTNERSHIP:3#; I LLC Q#
COMPANY NAME: E.F.WINSLOW PLUMING 8 HEATING I ADDRESS 8 REARDON CIRCLE I
CITY SOUTH YARMOUTH . I STATE MA ZIP 02664 TEL 508-394-7778 I
FAX 508-394-8256 I CELL N/A (EMAIL 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 -