HomeMy WebLinkAboutG-12-146 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
• (Print or T'y/pe) /�j
P T L 1/}/ 11/ 11a / ,Mass. Date v"%�7 20/1 Permit#612—J f-1 �o
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f Building Location ff ��' I//a el• � Owner's Name (/`�gi2>0 'ge_
CA_-.:a J/� _/ V
�.. • Owner Tell ete 7/f ?J%7 7 Type of Occupancy RIO
•GNew ❑ Renovation ❑ Replacement r Plan Submitted: Yes ❑ No
FIXTURES
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SUB-BSMT
BASEMENT
1"T FLOOR I
•
2Ne FLOOR
3Re FLOOR •
4Th FLOOR
Sr"FLOOR
6Th FLOOR
7r"FLOOR
8Th FLOOR r f /
Installing Company�oName. r(-(4'g5k/0 PHI (2) Check one: Certificate/
Address P.) 7?4A�94 (if (t/t / / I§'Oorporation Sat S/ L.
�5 jtnz%;j'V* ' /947 &1.6 51 ❑Partnership
Business Telephone# 5T/P) -,3°Y ///__7 78 0 Firm/Co.
Name of Licensed Plumber or Gas Fitter �T� - /-e A - A /S•
INSURANCE CO RAGE:
I have a curre lability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142.
Yes No D •
If you have checked des,please irate the type coverage by checking the appropriate box.
A liability insurance policy Other type of Indemnity 0 Bond o
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 •
Agent
Signature of Owner or Owner's Agent
1 hereby certify that ell of the details and information I have submitted(or entered)in ab applicatio re true: d =c• rate t• - best of my
knowledge and that all plumbing work and Installations performed under the permit issued fo ' cation w •'I omen-) e with all
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 .J.2�
•Master License Number /?1Le--
City/Town •Joumeyman
APPROVED(OFFICE USE ONLY)