HomeMy WebLinkAboutG-11-840 ' .4
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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C Wills City/Town: t:F II — ro
"I4s MA. Date: G "/3 ao(
e" Perms aJ
1244..3 1
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Building Location:15, g Jr/6 Rock 1%4 Owners Name: S 1 tl e e t, i'c 1 v S
GType of Occupancy: Commercial 0 Educational 0 Industrial❑ Institutional 0 Residential 0
New: 0 Alteration:0 Renovation: 0 Replacement: , Plans Submitted: Yes ❑ No 0
FIXTURES
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SUB BSMT. •
BASEMENT
151 FLOOR J ' I
2"v FLOOR
3""FLOOR
4'"FLOOR '
5'"FLOOR
6'"FLOOR
7'"FLOOR
8'"FLOOR
Installing Company Name: }RA ni VOlk P q /-f ,=AJC Check One Only Certificate#
Address:7O 60 54. G?u w`St 19-Corporation 6 2339
City/Town:}{ywmv,�/tspo..4 State: /M 04
0ir •77 ❑Partnership
Business Tel:
S'— 1 �9� Fax:
❑Firm/Company
Name of Licensed Plumber/Gas Fitter: r.2.Hn,'or C. C o,/,4
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 Yes 0 No❑
If you have checked Yes,please indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy 0/ Other type of indemnity ❑ Bond 0
OWNER'S INSURANCE WAIVER:lam aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement
Check One Only
Signature of Owner or Owner's Agent Owner 0 Agent 0
By checking this box U:I hereby certify that all of the details and Information I have submitted(or entered)regarding this 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 proves n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
Type of License:
By ❑Plumber � " � r{
Title �It)S ❑Gas Fitter Signature of Licens Plumb sFittef'
,'Master
Clry/Town.r. 40 ❑Journeyman License Number: 5'The
APPROVED(OFFICE SE ONLY) 0 LP Installer