HomeMy WebLinkAboutG-11-629 • La(C3 - (6 -11
SL. MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
`..art= Ci /Town: 4fly ow 1
Ali City/Town: �` cit � MA. Date: I I Permit# Gl I - 629
Building Location: S'k Amy Low( Owners Name: tmin V.‘11f
GType of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional 0 Residential 6
New: 0 Alteration:0 Renovation:A Replacement: 0 Plans Submitted: Yes 0 No al
FIXTURES
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SUB BSMT.
BASEMENT
1'r FLOOR 1
2ND FLOOR
3"1"FLOOR '
4'"FLOOR
5'"FLOOR —
6"'FLOOR —
7'"FLOOR
8'"FLOOR
' 11 t i Check One Only Certificate#
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Installing Company Name: -1no e P lbq c ti�
ID Corporation
Address:( Ht....) toS o... eaCity/Town: Qeflfl.S State: 1/4.
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ID Partnership
Business Tel:(SblSFS'-51 yr Fax:
IZTfirm/Company
Name of Licensed Plumber/Gas Fitter: J.-Rp A tso0 v.(
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 Yes$ No❑
If you have checked Yes.please Indicate the type of coverage by checking the appropriate box below.
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
Massachusetts General Laws,and that my signature on this permit application waives this requirement
Check One Only
Owner 0 Agent 0
Signature of Owner or Owner's Agent
By checking this box 0;I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and
ac to the bast of my Knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be In
omplian•e withnent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
t^ Type of License:
By \ I ►• ./�`� LI Plumber V c2 �� .c
Title a J as 0 Gas Fitter
•
nSignature of Liceni ed Plumber/Gas Fitter
❑Master
Cityrrown ,• - is la ❑Joumeyman License Number: 76.3.4 rrl
APPROVED(OFFI USE ONLY) 0 LP Installer