G-12-012 • ''` MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
-4(C\-,A (Print/ or Type)
_ y00$? 4+ ,Mass. Date 7/L 20 I( Permit#C 12 - 012.-
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I Building Location 35 tat//G o* Dc War AS-c , P /grain
Owner's Name n
Owner Tel# ($b81 685—/y!8 Type of Occupancy QCd/Q� jay
New 0 Renovation 0 Replacement vgt Plan Submitted: Yes 0 Nor/
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M SUB-BSMT
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BASEMENT -,
1ST FLOOR fl --.r7
2N0 FLOOR D •bL c. . Li ` t 7 1
3R°FLOOR •� q 11
__ _ 4T"FLOOR - JU _ C ! LQII ( ,J
- 5TH FLOOR -, _ BtdnWG� rr
I - - --- 6T"FLOOR -
- By "�- . • •"
• -7T4FLOOR . - . :. _ .... 1
I- l 'std FLOOR• ;.. ,rn .,
Installing Company Name-- RWST)/IS Ii7G
Check one: Certificate
Address - . : a?2 Mid- Ted, On vt - `[Corporation 1762. C
Wear yorms,41, MA 02473 0 Partnership ._A�
Business Telephone# ..57V-7r- /303 0 Firm/Co.
Name of Licensed Plumber or Gas Fitter FRhNK W 1 .odencg.
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 leaked •Les,please indicate the type coverage by checking the appropriate box.
A liability Insurance policy S Other type of indemnity ❑ , Bond 0 - -
OWNERS INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Mass.General Laws,and that my signature on this permit application waives this requirement.
_
-.__ - -.- _ Check one: .. • . :.._. . . -..
.. - .. - Owner ❑ `Agent ❑
'Signature of Owner or Owners Agent ," _ -.- r_ • ,_T �,
I hereby certify that all of the details and information I have submttted;(or entered)in above application are true and accurate to the best of rpy-°-
knowledge and that all plumbing work and Installations performed under the permit Issued for this aparcation will be in compliance With all l t
pertinent provisions of the Ma3sachusetts State Gas Code and Chapter 142 of the General aws. .. , . r -t--
By 7 , Type of License #
I l ! 1 1 'MC v 2oa/alc/G.. I..
- ,,- - - •.•Plumber , , i i Signature of Licensed Plumber or Gas Fitt ' i
Title •' Fitter_-'Gas fitter. _,_ ! _ I ._. _ 1 S
7791/)FMaster License Number .
City/Town - - - rneyman - -
APPROVED(OFFICE USE ONLY) - - - -