HomeMy WebLinkAboutG-14-654 1 %-,_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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��+ JOBSITE ADDRESS i i c 0 /i i s f'i OWNER'S NAME rn/f rki
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TYPE OR OCCUPANCY
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RESIDENTIA
CLEARLY NEW: J RENOVATION: J REPLACEMENT. 4J PLANS SUBMITTED: YES _I NO J
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L -- __�,AHTN,tNT INSURANCE COVERAGE
I have a • went'liability-insurance_polic or its substantial equivalent which meets the requirements of MGL.Ch.142 YES N NO J
or
I IF YOU CHECKED YES,PLEASE ATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ,
LIABILITY INSURANCE POLICY XI OTHER TYPE INDEMNITY _J BOND IJ
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 _J AGENT _J
SIGNATURE OF OWNER OR AGENT
I hereby certify that as 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. �G.am.. nl�noutil •-
PLUMBER-GASFITTER NAME Brian HA.IWOWS ECt I LICENSE# I5155I SIGNATURE
MP XJ MGF _J JP J JGF J LPGI J CORPORATION J# I PARTNERSHIP J# I LLC J#
COMPANY NAME:J'1L N/0/ 0SfSt niksi ants( Ltd I ADDRESS 1-11.7 rnee't, use ROCS I
CITY SOx►frJ 1 Op H O ni I STATE Oyu ZIP 02.,59 I TEL 569- 4/30 - '1311 I
FAX I CELL IEMAIL I
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ROUGH GAS INSPECTION NOTES 'IMS PACE Wit INSPECTOR USE ONLY FINAL INSPEC'I ION NOTES
/OP C A Tl _c ``g Yes No -- — -- — I
/1�3Pr7 � C THIS APPLICATION SERVES AS THE PERMIT
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&/.I-f_iI3S CIH tit l — /Hi ti -- fl'IAN REVIEW NOTES ------ — ----
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