HomeMy WebLinkAboutG-12-213 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAASSFITTING
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• _ (G "*ft cr O4h ,Mass. Datet}p t O 20_1_1__Permit#(i. Z o� 3
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._. __ Building Location Al )er�t s � Owner's Name��ropo rfl
.;._ Owner Tel# 60%'17b-,eStaType of Occupancy r—fj ,-9e
New ❑ Renovation 0 Replacement t Plan Submitted: Yes 0 No 16
FIXTURES
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VV 1 SUB-BSMT ,
riS BASEMENT I
t 1ST FLOOR
2ND FLOOR
3RD FLOOR
• 4TH FLOOR
5TH FLOOR
5TH FLOOR
7TH FLOOR
8TH FLOOR
Installing Company Name 1AppL-Itit<: t-PA 41\00_ Check one: Certificate
Address°Cp ftes \t Q,\ . s Corporation 0.100
10 rtict Ac-el . e a 'c-nc�, o','a19 0 Partnership,
Business Telephone# i -in9nr1fJ 0 Firm/`Co.
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Name of Licensed Plumber or Gas Fitter "CsrnE'S ` c' Rae,cLSOC�.e_A-0
INSURANCE COVERAGE:
I have a current ibility insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142.
Yes d/ No ❑
If you have checked ies,pleas ndicate 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 142 of the
Mass.General Laws,and that my signature on this permit application waives this requirement.
Check one:
Owner ❑ Agent 0
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered)In above application are true and accurate to the best of my
knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be In compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gen I Laws. �)
By Type of Ucense: cp-4.----
P) Signatur f Licensed Plumber or Gas Fitter
Title lumberatter
• aster License Number`('(1alrr"
City/Town ••Journeyman
APPROVED(OFFICE USE ONLY)