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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTII G
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ui�KYY>!Oc.�T�-� . Mass. Date �T— C19 cjCX.- j Permit #
Building Location_ n f1 AAcir (_--ro I Owner's Name /Li-j)q rri mclnq
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T,02m Uc.(Tr_j Type of Occupancy Res i lD f i l err
New ❑ Renovation ❑ Replacement Diane Submitted: Yes❑ 1 No471
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B—BSMT.
ASEMENT
1ST FLOOR
ND FLOOR
RD FLOOR
_
4TH FLOOR
5TH FLOOR
6TH FL'OOR' '
7TH FLOOR
;.
aTH FLOOR:J±
Installing Company Name . S'R t `G 5 i `A �_ i nL_ L�
Address10 1-1 i Tfa _MQk i T-%-4 R o tzi c.
1-1 u r_ n n r s YYi ra Ss C� I
Business Telephone (Sal) _ —1"7 3 - Ors ► <'
Name of Licensed Plumber or Gas Fitter \71700 L3' HE-,
- "Check one: " Certificate
tE�Corporation / 33 S
❑ Partnership
❑ Firm/Co,
INSURANCE COVERAGE:
I have a eurren�t�' bility Insurance policy or Its substantial equivalent which meets the requirements of MGL!Ch. 142.
Yes yid No Cl
If you have checked ve, please Indicate the type coverage by checking the appropriate box.
A liability Insurance policy ,2"' Other type of indemnity ❑ Bond O
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requir ment.
r Check one:
Owner[] Agent C3
Signature of -Owner orOwner's Agent '
hereby certilythat all of. the details and information.thave submitted (or entered) in above application are true and accurate to the best of my
knowledge and -that all plumbing work and installations performed under the perntitlssued for is application will be in oompliande with all
pertinent provisions of -the Massachusetts State Gas Code -and Chapter 142 ql?gnature
eral
By T of License:
Plumber cense umber or s it
T� GasfitterMaster Number
Chy/Town Journeyman
IC L