HomeMy WebLinkAboutG-12-730 ` °"oF ""G;q APPLICATION FOR PERMIT TO DO GASFITTING
� ;
1:el \g (OFFICE USE ONLY)
�_ TOVJ��114�Ff ��1)I�U By
,-8 ii MAY 22012 Fee: $
S�' aIn PERMITNO.6I2. 736
GBUILDING DEPT
By Date
Building ae (�v,ACQUC( 0 d Owner's VVl /n _ p fo
AT: Location Name �� �s isl
ype of Occupancy
New 0 Renovation 0 Replacement
Plans Submitted Yes 0 No❑
COre I
y co a x H en
w
co re co F Li
0003 /=N x x
Z O x Q � y Z O O Z co
m N FW- 6 W O c. O W Q
co ce to 0 U 6 x N W Q cut O rt W
0 la H Z j I- Z F W W V' O > LL i U J . W (�'
Z W > 2 < fx Z a X CO 0° o 0 w &I o w lx- M1 v
LI' o o x u. E R o o .j V x > 5 o. r o W('�,
SUB-BSMT. V
BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR
(PRINT OR TYPE) ��� / Check One:
Installing Company Name �✓�Q,I[i� t`�L(\� 0 Corp.
n ►
Address Ur( V ►' 'qi `e�1 ' - ❑ Partnership
11-keUJ S V V1c 0 ?10 f ❑ Firm/Company
Business Telephone l/ 7 /l 73
'(� , n r
Name of Licensed Plumbe�Gasfitter7 (rjvLf V-3 p�14 Ci �/E-�
INSURANCE COVERAGE: Check e
I have a current liability insurance policy or its ubstantial equivalent. Yes No 0 ,
If you have checked yes, please indic a type of coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity ❑ Bond 0
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 requirement.
Check One:
Owner 0 Agent ❑
Signature of Owner or Owner's Agent
JCLLC Bout/tut/cc
I hereby certify that all of the details and information I have submitted Signature of Licensed
(or entered) in above application are true and accurate to the best of Plumber or Gasfitter
my knowledge and that all plumbing work and installations performed Pt, to 0
under Permit issued for this application will be In compliance with all
pertinent provisions of the Massachusetts State Plumbing Code and License Number
Chapter 142 of the General Laws. TYPE LICENSE:
0 Plumber 0 GasfitterMaster 0 Journeyman