HomeMy WebLinkAboutG-12-369 .1 . MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
1;11_ Z City/Town: VA4#flbu>if MA. Date: /2 -i3- 1/ Permit# an -3 4 T
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Building Location: 23 &G'Jv2C ay LN Owners Name:GType of Occupancy: Commercial❑ Educational❑ Industrial❑ clinrti.14:titoerl0 Residential
New: ❑ Alteration: 0 Renovation: 0 Replacement:0 Plans Submitted: Yes 0 No 0
FIXTURES
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BASEMENT I
1" FLOOR
2"u FLOOR
3N°FLOOR
4'"FLOOR
5'"FLOOR
6'"FLOOR
7'"FLOOR
8'"FLOOR
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Installing Company Name: KLfntc.dr PLu at hi erq Cravat S Check One Only Certificate#
Address: ($ 1u11A Get N City/Town: 141 ❑Corporation
7AQWrt14 State: ►Kn
o Partnership
Business Tel: cot 1,4 If`Igo Fax:
cii Firm/Company
Name of Licensed Plumber/Gas Fitter: /3i241-N /&t,new7
INSURANCE COVERAGE:
I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142 Yes B'No❑
If you have checked 191,please indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy 0 Other type of Indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER:I am 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 ❑ Agent 0
By checking this box 0;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 permk issued for this application will be In
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By Type of License: A
0 Plumber S /�5�, rade
Title
0 Gas Fitter gnature of Licensed Plumber/Gas Fitter
®Master
CirylTown Journeyman License Number:
APPROVED(OFFICE USE ONLY) 0 LP Installer // 7'70
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