G-12-552 0
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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_ City/Town:LJ.,yg rM490 421 , MA. Date: 24972, Permit#GIZ"552.
Building Location: /03,45&c'gn .4' 0-0 Owners Name: 'Jaa'P Cun0JOS✓/nG,.t.,...
GType of Occupancy: Commercial 0 Educational 0 Industrial❑ Institutional 0 Residential<
New: ❑ Alteration: 0 Renovation: ❑ Replacement:g Plans Submitted: Yes 0 NCI
FIXTURES
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z 1- q� zzzQQQQ > 20 12 Ce z 0 I FE6n ccal �2��? 2�/012�,
K to U V' O 6 0 O W BJILDING DEPARfMF�17
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0 0 0 u. 0 0 _ _ 4 O a z z CCI- > > > 3 0
SUB BSMT.
BASEMENT
1a' FLOOR '
tO FLOOR
3K0 FLOOR
4'"FLOOR
5'"FLOOR
6'"FLOOR
7"I FLOOR
8'"FLOOR
� Q� (1 Check One Only Certificate#
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Installing Company Name: M C� (` r C� 1"
'7 /� A ,� /' I ❑Corporation
Address: C.,c 72 u'rtc//UCCityrrown: CL) 7' State:
❑Partnership
Business Tel:31C 7) ;59 Fr? Fax: ,//3—
7 V pZ
l0 � . l Firm/Company
Name of LI en ed Plumber/Gas Fitter:
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 Yes 0 No®'
If you have checked Yes,please Indicate the type of coverage by checking the appropriate box below.
A liability insurance policy tg. 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
Massa husetteneral Laws,and th=t my signature on this permit application waives this requirement
'Sr ii Check One Only
/'Pm ���* `'"�f rue01 Owner 0 Agent ❑
Si/ature of Owner or O • - s Agent - l
B checking this box ■• ereby certify that all of the details and information I have submitted(or entered)regarding this application are true and
accurate to the best o y Knowledge and that all plumbing work and Installations performed under the penny Issued for this application will be In
compliance with all •ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
B Type of License: (2
Y ID Plumber
Title
0 Gas Fitter Signature of Licensed Plumber/Gas Fitter
0 Master /
City/Town ®JC�6ourneyman License Number: / / " /
APPROVED(OFFICE USE ONLY) 0 LP Installer