HomeMy WebLinkAboutG-11-525 -,-
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
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)• 5y padv nt 1'te ,Mass. Dateeu�rA1 20 11 ,Permit
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=E.-r_g7 Building Locatio wear's Name
�..•a Owner Tel/ 1'362 -7eleiet Type of Occupancy ft" (Clete
New 0 Renovation ❑ Replacement X Plan Submitted: Yes 0 No}"
FIXTURES
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01 W N P Pi 2
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SUB-BSMT
BASEMENT X
1"1.FLOOR
24o FLOOR
3R0 FLOOR
4TH FLOOR
5"FLOOR
6Te FLOOR
7T"FLOOR
BTM FLOOR �j
Installing Company Name Ef/41//25/[:/O/ A-1 i2 Check one: Certificate /
Address GG0 7521-71,64:4 of of/t &corporation Sae& L.L.
,Ji O/7' i_mi•gh 'iii i o26 / 0 Partnership
Business Telephone# �j7 A� :.Y -7 7 7ti
v f) !4/) /�) 0 Firm/Co. )
Name of Licensed Plumber or Gas Fitter � •7/0/12] .J? (J
INSURANCE COyERAGE:
I have a curve [ability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142.
Yes No ❑ ACCEPTED
If you have checked 'Les,please [Cate the type coverage by checking the appropriate box.
A liability Insurance policy Other type of Indemnity ❑ Bond ❑ BY:
OWNER'S 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 o :
Owner r gent ❑
Signature of Owner or Owner's Agent /
I hereby certify that all of the details and information I have submitted(or entered)In abo appll e true = d : cu • •to the bes • 'y
knowledge end that all plumbing work and Installations performed under the permit Issued ap lion wit b• n co pliance wi i •
ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Law .
By Type of License:
•'Plumber Signature of Licensed Plumber or Gas Fitter
Title •Gas fitter
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•FMaster License Number
City/Town •'Journeyman APPROVED(OFFICE USE ONLY)