HomeMy WebLinkAboutG-17-1185 11MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WC
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kJ"' CrIT 'i42m&S4 /,i a-1-' 11A DATE 93/4 - eriot a n- , 1/15
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TYPE OR OCCl1PANCYTYPE D ®UCATIONnL® a
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PLANS SUBMITTED: YES 0 NOLs
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USURMICECOVE CAGE
I have a current habit,unite poicy a Is substantial egarafst Wide meets Bre requirements of MGL Ch.142 YESAI NO
IF YOU caws YES,PLEASE NWICATETIE TYPEOFCOVERAGE 8T•-- 16TIEAWNOPRMTEBOXB9AW
LIABILITY BISURANCEPOUCYJ4 Con ME smart0 BOND 0
OWNER'S INSURANCE WMYEJt Ian aware that the iaape dors set Iae.the insurance coverage required by Chapter 142 of the
Massachusetts Genera!lsryirdOat raysigoatwemd'aP application tithisrugrirmrwd.
CHECK ONE ONLY: OWNER - AGENT 0
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PLUMBERcASFrrTERNME?i MAC'fIr3E&OE,/ 1uceaaESi SIGNATURE
MPS ! MGE,�'i NPD sr0 LPGID CORPa?ATION, i '�e}77e I mum:RawDNI }cm O.! i
COMPANY NAMfa�ri�K/J tYaa E.nE t r�AcoRESSj Al Lneek /Qac '
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ROUGH GAS INSPECTION NOTFC THIS PACE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ ,gyp
FEE: $ PERMIT$
ELAN REVIEW NOTES, OA c-7 71/
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