HomeMy WebLinkAboutG-11-847 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
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t �/ yRr'rM(r ,Mass. Date b-13 20 (1 Permit# CI(- 8 "i7
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=( rti— y BuildingLocation IVCD �U�3M 14 W4i4 Owner's Name /P reit-El
•';• Owner Te]# 5O8' 11$ •Geo rj 3 •
Type of Occupancy X31 PENCE
New 0 Renovation 0 Replacement 0 Plan Submitted: Yes 0 No 0
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FIXTURES
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0 d x og cs E g 3 c 2 8 m �' c R o r'
lik • SUB-BSMT
BASEMENT ,0)C r
15T FLOOR
2N0 FLOOR
3"°FLOOR
4T"FLOOR
5TM FLOOR
61"FLOOR
7T"FLOOR
8T"FLOOR ) /� 1
Installing Company Name
tkii4W-5/GL(1 11-,' (2' Check one: Certificateatte /
Address 0 � '� Er(I/ t§•ivoration jjS/ CL
�Jr j%±s ,; yciA 7' /MK-7 0966/ ❑Partnership
Business Telephone# crA :4 Y " / 7 7e n 7 0 Firm/Co.
Name of Licensed Plumber or Gas Fitter �kpli-el / •40/45ji1(t/
INSURANCE CO ERAGE: •
I have a curre lability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142.
Yes No 0
If you have checked lea,please mate the type coverage by checking the appropriate box.
A liability insurance policy is Other type of Indemnity o Bond a
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'-:
Own- •ent •
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered)in a••ve appli . '.• are true and a.• r,..:t•, e best
knowledge and that all plumbing work and Installations performed under the permit issued •. •s ...li ation will be I. .'rpE ince ith - •
ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws
By Type of License:
••Plumber Signature of licensed Plumber or Gas Fitter
Title •Gas fitter
✓•M / n/g
aster License Number ./—�'
City/Town ••Journeyman
APPROVED(OFFICE USE ONLY)