HomeMy WebLinkAboutG-12-722 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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';11- j' CityfTown: `11112)400119 MA. Date: 5/1�17Z Permlt#G12- ?22
.---e. . Building
Building Location: "Mb. 6Q-07t-33LA, Owners Name: '4) N 5 n(-,
G Type of Occupancy: Commercial 0 Educati al❑ Industrial 0 Institutional 0 Residential
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bt New: ❑ Alteration:0 Renovation: Replacement: ❑ Plans Submitted: Yes E No 0
FIXTURES
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BASEMENT
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2" FLOOR Baa -3 _
4 • FLOOR
FLOOR 5 FLOOR � _.
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��� Pip f Check One Only Cer—mss. #
Q Installing Company Name: I' Cs
-4- 0❑Corporation
Address:Pi ,J 1701 City/Town: , j4y5 state:,A4'3-
❑Part iership
� Business Tel: Tar- 70 - 2-7701 Fax:SS-l�Y-7/.D-,9 33
~ Flan/Company
Name of Licensed Plumber/Gas Fitter:4 mat-4•A. trout
INSURANCE COVERAGE:
J . I have a current Jlabllity Insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 Yes 0 No❑
V If you have checked Yes please indicat he type of coverage by checking the appropriate box below.
A liability insurance policy Other type of Indemnity 0 Bond 0
t OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
‘.9 Massachusetts General Laws,and that my signature on this permit application waives this requirement
Check One Only
Signature of Owner or Owners Agent • Owner 0 Agent 0
By checking this box pi I hereby certify that all of the details and information I have submitted(or entered)regarding this application ars 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.
•
By Type of License:
0 Plumber
Title ❑ Gas Fitter Signature of Licensed Plumber/Gas Fitter
❑ Master
CltytToym ' OJourneyman License Number:
APPROVED(OFFICE USE ONLY) ip LP Installer l
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