HomeMy WebLinkAboutG-11-699 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
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f = (/ 3. � cf2 r y\i7 U1 Mass. Date it• g 20 !I Permit#C4 — V t (1 '
—=4. �= (j / t I) p f1 Owner's Name �6 r Y \O P�A--4-4
Building Location I
�• Owner TeW 37�� 7' / T/ P2£S r Type of Occupancy &Cr" —11 .0,j
New 0 Renovation 0 Replacement Plan Submitted; Yes 0 No16—
• FIXTURES
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SUB-BSMT ,
_ , BASEMENT
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CD I' 1 H FLOOR
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.__ ' M 2ND FLOOR
_ 3•D FLOOR
j 4TH FLOOR ,
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'�, 'IC STH FLOOR
i�-..r: r_I 6TH FLOOR
-- --- "' .i 7TH FLOOR
BTH FLOOR )
Installing Company NameEf14'IiIsk)/i_) P-/-r (19 Check one: Certificate
Address 0 ��Figed1/f0/ C 3E'eft. J / 6'�orporation .,�. Sf (-1--
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�Sr //7anI%/(UV* /i A 096651 0 Partnership
Business Telephone# c )C7 cY 91 —7 77a ❑Firm/Co.
Name of Licensed Plumber or Gas Fitter S-'71 —e7) -40/12-51A)
INSURANCE LEVERAGE:
I have a cunee ability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142.
Yes No ❑
If you have checked yam,please tate the type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter 42 of the
Mass.General Laws,and that my signature on this permit application waives this requirement.
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caner kept •
Signature of Owner or Owner's Agent
I hereby certify that all of the details and Information I have submitted(or entered)in a•• -lion are • e • d : urate to th- •: t of my
knowledge and that all plumbing work and installations performed under the permit issued s applicati• r •. co r •Ilan - th :'
•-di—• •rovisions of the Mass-chusetts State Gas Code and Chapter 142 of the Gene PH .
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By i t a Type of License:
/ •
dumber Signature of Licensed Plumber or Gas Fitter
s
'Mel 0 P1c ,rl •Gas fitter /
•"Master License Number 42.2--it�-�J./-it
City/rownFtIQl •'Journeyman
APPROVED(OFFICE USE ONL i