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Home My WebLink AboutBLDP&G-18-005586 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YARMOUTH MA DATE 4/6/18 PERMIT# BLDP-18-005586 /1/4* JOBSITE ADDRESS 20 SALT MARSH LN OWNER'S NAME MULLER CARL R y/ �-v! P OWNER ADDRESS LEWIS DEBRA J 20 SALT MARSH LN WEST YARMOUTH,MA 02673 TEL I T TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL PRINT CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YESD NO❑ FIXTURES 1 FLOORS—› BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 , BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM _ DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM _ DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER _ FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) • KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL _ WASHING MACHINE CONNECTION WATER HEATER 1 • WATER PIPING OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER TYPE OF 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. 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 accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Stephen Winslow LICENSE#2298 SIGNATURE MP 0 JP ❑ CORPORATION D# PARTNERSHIP❑# LLC ❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE ❑ 0 DCDMIT FEES$ PERMIT# PLAN REVIEW NOTES tio IC Corg' S'26 1/0 , 60 `7 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT A TO PERFORM PLUMBING WORK r�0 _ _4(_5c CITY p ._.. ..._f 4/ MA DATE - - -- JOBSITE ADDRESS 7 ,► OWNER'S NAME • 1) OWNER ADDRESS , �- TEL ' r f]yAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL u RE PRINT RESIDENTIAL CLEARLY NEW: [j RENOVATION: Li REPLACEMENT:SW PLANS SUBMITTED: YES E NO[ FIXTURES FLOOR-} BSM • 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB ��_. .-- -- 'I:-----�r. . - ..1� _._�(_r .._--°I - ----� - - �'I- - -�� .__._—+ --. !•. CROSS CONNECTION DEVICE I I. '17__ I_, . I ;(" _. l " r �-' , .r: DEDICATED SPECIAL WASTE SYSTEM I._ . ....I I _�. . .-._.. .._ ...,-.:._' _ Asi DEDICATED GAS/OIL/SAND SYSTEM IIPII . r _ .. - ; _ �---_. .{.•_ .rDED1CATED GREASE SYSTEM 17771 • ��1"`DEDICATED-GRAY WATER SYSTEM (. .:---- �� '• - .. r DEDICATED WATER RECYCLE SYSTEM h - • - - DISHWASHER II • �tI�_.-_�L~• -, . i . . _ �.::-_--_--1-`r�_;---.-r— -- L - ;l..- EDRINKING FOUNTAIN _ . I. � 'I - FOOD DISPOSER _-_ FLOOR IAREA DRAIN L_Y-z=�r 'L.-_ _ ��:-..� L_ i -- jlI _ I. - -,�._ _ �i {- _' _ INTERCEPTOR(INTERIOR) I.T_ `� _ I . ��f^ - 'I. _ __ -_ 'P_�_ . . 1:--. --. I: _�; .r...�.�.,rr..� i. 1 •mow_ KITCHEN SINK -__ I yIl i! -F��, l - ill -_�� ,{ __ • LAVATORY - -- -- _... �-�� - - � � (�- �_ I I- I . ROOF DRAIN ( j1 �; f --- -�. - _ _...._ {�__r--------�(� ' 71 SHOWER STALL 1P_1l ..r---_i[-r�+ (----.� T'. - SERVICE I MOP SINK ---=' —-- _� TOILET I �1(. 'L_._. i -1- � _:: •[.--- � � �.- URINAL :-z-, ._ .-`) — C 1 � �L_ WASHING MACHINE CONNECTION i If ' III _I WATER ATERALLTYPES _ ��. `. ; _.. - 'I . _ _ . . -? 1 WATER PIPING OTHER 1. - --- I _il I _ n �--'n il. 'r 1_- ( ;E -_�� ...i;LT __ I---. 'h�•�--...�_a f�____�i_ ,,r^�_ I- _�_ I. . I —`C-: _`f_._. ..;I ,,I______: T._.�_��F .� �� [77.7..= C. .�� - _3� r : „ (- -ar_ , r L�::__7 I.:_ _ � ( . -. .77 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES El NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY � OTHER TYPE OF INDEMNITY [ BOND fj 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 ONE ONLY: OWNER [I AGENT (Cz 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 accurate to the best of my knowledge and that all plumbing work and installations performed under the permit Issued for this application will be in co liance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws, C , t A4. . PLUMBER'S NAME STEPHEN A. WINSLOW LICENSE# l 12298 SIGNATURE MPL JP `I CORPORATION 7# 3281J}PARTNERSHIP # LLC[ # COMPANY NAME EF WINSLOW PLUMBING & HEATING 1 ADDRESS 8 REARDON CIRCLE CITY SOUTH YHARMOUTH Y _ 1 STATE M_ ZIP 02664 y TEL 508-394-7778 • • FAX 508-394-8256 i CELL - -- �'�-----�-- - __ NJA EMAIL bults�ayabie@e�winslow,com i APR 05 2018 1-4 BUILDING DEPARTMEN ey:- Department oflndastrialAcctaenis' ' • _ = I*--=Lk== I Office of Investigations ,eln= 600 Washington Street %• i I•= Boston,MA 02111 .. . ;.)• -„0 ` www.mass gov/dia • Workers'Compensation Insurance Affidavit:Builders/Contractors lectri Please Print Legibly Applicant Information ' (Business/Organization/Individual):Name C'e �tSe„, Y( "^bt✓cL lIt0.t'1 \® inc• .� Address: K4n Cistte- City/State/Zip: Soo h ‘icY "1" COI' Phone#: `50a-3cI4'1T7St • Are you an employer?Check the appropriate box: Type of project(required): ,,N11 am a employer with 70 4.0 I am a general contractor and I 6. 0 New construction employees(full and/or part-time).* have hired the sub-contractors Remodeling listed on the attached sheet.t ;. I ship a sole proprietorn employeeso pestner- These sub-contractors have 8. 0 Demolition ing have meo inay workers'comp.insurance. 9. Building addition working for any capacity. [No workers'comp.insurance 5.0 We area corporation and its 10.0 Electrical repairs or additions required.] officers have exercisedtheir all work right of exemption per MGL 11.0Plumbing repairs or additions I,❑I amys a homeowner workers'r doing c.152,§1(4),and we have no 12.0 Roof repairs myself.e r d comp. employees. workers' insurance requved]t [No13.❑Other comp.insurance required.] lay applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :ontmctors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. . 1 4Im an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site [formation. isurance Company Name: C k Yt/0.)1 C n p1NCA elQ . $a 1 A. Expiration Date: —]— au-)olicy#or Self-ins.Lic.#: � yy 11 ib Site Address:D.3 vkon W-ea-(rh skV'Q Cl e�ktl P1 lI City/State/Zip: 6�N 4= .ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). allure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a ne up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine Cup to$250.00 a da a:ainst the violator.Be advised .:t a copy of this statement maybe forwarded to the Office of tvestigations. the DIA for insurape- overage veri. a,on. t do hereby certify u penalties o crjury that the information provided above is true and correct. _�r� 'r. .-►.. Date: i o. I a01 i„a - ► hone#: `i-777 Official use only.Do not write in this area,to be completed by city.or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE April 06, 2018 PERMIT# BLDP-18-005586 JOBSITE ADDRESS 20 SALT MARSH LN OWNER'S NAME 4 IULLER CARt-R c5 ' tII/ //alive G OWNER ADDRESS LEWIS DEBRA J 20 SALT MARSH LN WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL Q PRINT CLEARLY NEW ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED. YES NOE FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES ❑ NO❑ IF YOU CHECKED YES. PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF 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. SIGNATURE OF OWNER OR AGENT I hereby certify that ail of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Stephen Winslow LICENSE# 12298 SIGNATURE MPQ MGFE JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME STEPHEN A WINSLOW ADDRESS 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT❑ ❑ FEE:$ PERMIT# PLAN REVIEW NOTES 1-770. (X3(1° / ° 4t4"- 616, g g'7-6' 1 -2,3 ., E MASSACHUSETTS UNIFORM FORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK • =u � ..M.I ►'i .IYw•.. IY.-✓_ .�N—..� . __..'"b .iV•..—._ .. . RV_e_•�f • 770.. .. � �= CITY MA DATE — - / ! PERMIT# I&!: -/�x -n wait 1 .5 „slip JOBSITE ADDRESS OWNER'S NAME ,11.. _ _� �__ A._�___ .A- _ y ;�OWNER ADDRESS , 4. Fa TE I 'Olt %FA Lo====:::11......,•••••••••••1 X R.O TYPEPE : i . , dr PRINT OCCUPANCY TYPE COMMERCIAL[ � E' C L TiONAL D RESIDENTIAL /A CLEARLY NEW: [21 RENOVATION: E.,:l 1 REPLACEMENT' ?•: PLANS SUBMITTED: YES ,E___1 NOri___1 APPLIANCES 7- FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER '.I 11 ....; `......_....� T - ` I�.� � 1 I- -- .._t L.�...r~-' I- --.. . ..� I . --..' .. . . i�I_.... . . I BOOSTER LIL ' I l.. .. .. l� ._�_ `� �.��I....�.. I ► ETETh__-- - . .�: .. __i ___. -' .. ..<-�I.- CONVERSION BURNERS[ifL1ITTEIIi1Ltl --- I __ I��..- I _ _ I.. _ -- -----, :.....-►;------- . .. _. . .` . . -__r�w--•--- -, . , L. .. fr 1 'i._ 4; _.4 i ; (.._ i l ,.I , I� i. I--- ;_ i � L_....�._... DIRECT VENT HEATER I. .__ . -�• (-------� I.�.�._.� I. I _, I . .. I� _ I._ w. i i� ___ I . 5 1I.�� I_ I. . l.. J--- -II_ . . . . DRYER Icy .w ': i_ . _ I �__._=; _ i�----w; I�._. _ lr _ _ `I �___ __ _ __ _ -. FIREPLACE I _..... I: .. __.i i- -__.._' :_.__. I __�;- - 1 . -� !. _ ► i- - -. it _: ;� i._, . . . _cl FRYOLATOR ;- � 1 ; I . .0 _. �; L -.�._ � I. ..._.` ,. .. .��_= ;. FURNACE i. i I_ �' L . , 1-- ( _ I ��I. __ ._ .� 1_ . . . -1- I . . i L- f 1,. I, _ i r�. GENERATOR -�_ I ._ .. 1_-: -1,. __.._ I.__ -• : : 41 .. .� I . ... i_ i_ - �__ ._-; I•--- I _. ' I_ GRILLE -I:_ I. _� -.._�.:11- --F.,_------ __......_:t 1.. _,�.-r.. L-.r__... i_ _' r I - -'-..._ . i_ . ..-- I---. ... I_-.. ..:_,' INFRARED HEATER 1w. ._ I. ' �. . (, . _. I LI. . . . I _. - 1� ' - -_ Iw. I` . _ ! . __? !-_ . .<<.. --- . LABORATORY COCKS . I. �-- : I-----.... �' I __...:---, �-.__ ,, ; .. � �._._.__��__-----_rL _, I_..-. _ .' I�.:.. . I. . . .... _, 1__.._-:�,i---- :► I �-_�I-. - _. . MAKEUP AIR UNIT I- _ - .- - --' _ .,.__.___� -.- ,I_ _ � ` _ .._' - : . _. .. _ --_� . . OVEN L__JI___ _ I !� _ . . �I _ W�i_ �i�_.�' _. . �I � i_ i. —!1 �._� Imo_ II . ` I '�I . _- _ POOL HEATER 1.�--:_._- (: . . . -' I . . !. . . ._ ' I-_.11 . . . .i; _.,. _ f 1____-- I__.__.__a i --:_�j_ _ �I_•-. .► i. _. ._.: 1.-. �, �L . , ROOM / SPACE HEATER [ i: l ....__.� I- . .._ _l i__.. . _ , 1 .�......-; I__ -. I.. .. f:LTL ... ._ I r . ` ` _ iL_ROOF TOP UNIT l _� j _; I _ _ I.Iv�T,3h___�-'I - j.. . ;I fi __- i A(. . ;_I f! l..—._. _ F I: ►: TEST [....._,: i-- _ i +' I_ _ .._ ':!. —_—_ ( '__.--- -.. !I _. _ _ I. _ _ i �, �I, ..- . I. .. ..___ L.. _. _kl_ .. .-.il_.-..._ UNIT HEATER r : I_._. . , �__..._.- l I _ • I _ . .- .' ��- ci --_ I. I _ .I, I I_. .. , _.` UNVENTED ROOM HEATER ! I .. ;;i�_-__� I- +�I -� I.. �- !:- - - - < . I-=- ._ ►i 1: . . -..1 1-- -. .h j.. .. L,:: WATER HEATER LiiI1fI i . . I ( ._ ; L�___�. 1 ___.. ' _ i____ -; I . I�4 _ 1. . .. .(_. _ I._ _ . . .. ► Imo_ 1. . - OTHER � JLJI__ L__ ifliiTi ,.�..�.�..—; 1 . I. _ `..1 _._� i__.._.�.� I — —_--�,I� _--1 , — . . -� . - . _[I. l;1 il _aCat:.•: .=---r.�z zZv a:.-.lr':s:csatVi:7t-Inc::it......,...........r.gmvir r-r=n s•--=u, I. . . I.. ....'• .. L-. i•-�- 11.•, . - S .. M~' `. •_� . ' J.._..,.._.. r...• 7 r J 1 I • L•.•1'C-r! ��C� i 1 _'si"'S... i I ,... .- 1.r7:--=... Lt: •��,i .dl. '-' ..w ate' S. INSURANCE COVERAGE I have a current liability insurance policy •or its substantial equivalent which meets the requirements of MGL, Ch. 142 YES LI NO L 11F YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ell OTHER TYPE INDEMNITY L 1 BOND /24 •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 ONE ONLY: OWNER Ell 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 a accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complia with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ` /- 11*-41...12-Z:Z-4.- PLUMBER-GASFITTER NAMELEPHEN A. WINSLOW I LICENSE 4.12298 SIGNATURE MP CZ] MGF LJP CJ JGF L.,—'11 LPGI CORPORATION '_# [3281C J PARTNERSHIP ._�D# � J LLC [J# ,�-. �� COMPANY NAME: EF WINSLOW PLUMBING & HEATING .1 ADDRESS 8 REARDON CIRCLEii r.a_c....s •-" :L7:...'-'7CL3.='_ ..--T�' ._.iv_a...;�...�.a..+�..a..aa: :.�ST�. .. .."...-:._.. .7.. - - ....i-..=-.-..ur.�a.�u ..--:.r..L��..r _ . __ .-...a - --..r:s_u..iARs..-r.._..-...Sr+..r:.: =.- ..a-.....-_.w w. ...........-++... L9266 iCITYISOUTHYARMOUTH STATE MA ; ZIP • " - - I ..ii....,... - ... _..._...._-.--..-6.�_...- . .r._.ti+-w�-��+fir..- --..J-1-r+Wr ' .�i.V1.+-: i:..rtl.+ I_.,. . ..-.d. . M1. . - ✓.ram+• . IL laillik sail iiii ilia FAX 508-394-8256 CELL NIA ;EMAIL accountspayable@efwinslow.com .L.-_.-_-_-_..,-i._.,x......_..._...__._._...�,. -J�xcr_:t .- -rssr. . _ . _,.r.... -c--.- _ APR 05201S w )'- if> BUILDING DEPARTMENT • By - - • NO * l Dci ar'treriit of industr'iai zilcciaenes t. `►.— Office of Investigations ,;elt61.7 b 600 Washington Street Ins 4;mmBoston,MA 02111 • ' 1111 5 www.nizass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Pluumbers Applicant Information ` ` { Please Print Legibly • Name(Business/Organization/Individual): E,C. v11 i tr\S 1 evv �(V„,AV'w`tci l�{(��✓vA Qs_, 0 6 J Address: Qeotdn C Etcl • City/State/Zip: Phone#: 5 - 39 i-1 Ti Si Are you an employer?Check the appropriate box: Type of project(required): f I am a employer with -7O 4. ❑ I am a general contractor and I 6. El New construction employees(full and/or part-time).* have hired the sub-contractors ;.❑ I am a sole proprietor or partner- listed on the attached sheet.Y '• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its officers have exercised their 10.❑Electrical repairs or additions required.] i.❑ I am'a homeowner doing all work right of exemption per MGL 11.11 Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] my applicant that checks bolt#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site tformation.tsurance Company Name: AYI-0•.,.1 ('J k}o.A < s'urck n(.41, �U,•, VIL-1 olicy#or Self-ins.Lic.#: B al • Expiration Date: c.—[ — apt )b Site Address:o23 G+vvrvUn\.rf-ea -} . •Q, e `S I b1\ City/State/Zip: O,,'-1 l�7 .ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). allure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine Fup to$250.00 a day_against the violator. Be advise ]rkt a copy of this statement may be forwarded to the Office of tvestigationsi the DIA for insurape overage venfrc�lon. do hereby certify unc e l e ains ani penalties of(pe/jufy that the information provided above is true and correct. ignature--._. 4 ,ram. Date: 3-1 :3i 1 aokb+ hone#: .c I)�,'• n4. 7 7'7X Official use only. Do not write in this area,to be completed by ci0.or town official. • City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: