HomeMy WebLinkAboutG-14-008 "oF"""""y--- APPLICATION FOR PERMIT TO DO GASFITTING
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PERMIT NO.
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Gsin ////ti��..fli�,,..;IML r Date 2617,
O''guildin /�l Owner's
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AT: ocation /MASS L.),$£T`r5 ��>G Name
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Type of Occupancy Rin lrALr_ c
• New 0 Renovation 0 Replacements.
Plans Submitted Yes❑ Nog
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SUB-BSMT.
BASEMENT i
1ST FLOOR
2ND FLOOR
3RD FLOOR
(PRINT OR TYPE) Check One:
Installing Company Name jNiJISP01Zr Pi.-Adt . 0 Corp.
Address 2 9 OPPFJZ CDLI>dni LoAD 0 Partnership
- 'eA/S `Ail
• - 4111 $'Firm/Company
Business Telephone LSDB'7,0 - i U a
Name of Licensed Plumber or Gasfitter Kt clAPr12D 214UI3'6
INSURANCE COVERAGE: Check One
I have a current liability insurance policy or its substantial equivalent. Yes JX" No 0
If you have checked yes, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity 0 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 Law , and that my signature on this permit application waives this requirement.
( I Check One:
(tel Owner ❑ Agent 0
Signature of Own or Owner's Agent
I hereby certify that all of the details and information I have submitted ature 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 ✓le 7 2 S 9
under Permit issued for this application will be in compliance with all I
pertinent provisions of the Massachusetts State Plumbing Code and License Number
Chapter 142 of the General Laws. TYPE LICENSE:
Plumber 0 Gasfitter 0 Master gJourneyman