HomeMy WebLinkAboutG-09-447 r;A, APPLICATION FOR PERMIT TO DO GASFITTING
tgion (OFFICE USE ONLY)
• II By
.� .
:;w :: '' ' Fee: $ �'/
JAN o 5 2009 r PERMIT NO. Al 1
GrAW,.%r• Y AS/t!
BUILDIV ruti o C(C Date /^ - O
Buildi a` _ l Owner's
AT: Location T Name Pity I al 5;0 /CC �;cgUS'
y n,N1 ccf-f"H •
Type of Occupancy 5' r
New Er- Renovation ❑ Replacement❑
Plans Submitted Yes❑ No❑
ID
111111111
HaO oCE
lU
K >
SUB-BSMT. flUSf111MEn nEllnEfnallin fl
BASEMENT Int11111.M11111.1111.LarlIMIEMMEMEn
1ST FLOOR FIEMIN11.....11111111t'....111111.......
2ND FLOOR 1............. 1..... 11.1.....11111.
31113 FLOOR NIMMIIMIIIIIIIIIMI'IIIMIEMEMIIIIMEMIN
_TD ik J 2 Cc) Y2411 i 1". " [?bil• 9_1(F r'& 4.
(PRINT OR TYPE) Check One:
Installing Company Name ( en/ (joy/cl f F /t -�i4-6-Corp. L73?sr
Address Prb 8 o V G 2-C) ❑ Partnership
t.a! r(y4iveVc S pori 02 e O2.&7 -Z
❑ Firm/Company
r.
Business Telephone c° t 1.7 5'
Name of Licensed Plumber or Gasfitter rig Hti e i s _____ oy/v`
INSURANCE COVERAGE: Check_O�'
I have a current liability insurance policy or its substantial equivalent. Yes LE No ❑
If you have checked yes, please indicate the type of 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--
Signature of Owner or Owner's Agent ,
L/ "
Alr
I hereby certify that all of the details and information I have submitted "M '
(or entered) in above application are true and accurate to the best of Plumber or Gasfitter
my knowledge and that all plumbing work and Installations performed &' 8-0 2
under Permit issued for this application will be In compliance with all
pertinent provisions of the Massachusetts State Plumbing Code and License Number
Chapter 142 of the General Laws. TYPE LICENSE:
0 Plumber 0 Gasfitter eMaster 0 Journeyman