HomeMy WebLinkAboutG-11-529 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
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ori gi YAP-M.04FH T'C1? ,Mass. Date 20 11 Permit# y I I —e-5251z I_
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t,I gI Building Location2Z W It (1(' Owner's Name V V 7e
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..• Owner Tel/ SW•qjq • 74-9)1 Type of Occupancy 4([00‘..TG7r'
New 0 Renovation 0 Replacement Plan Submitted: Yes 0 No)C
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SUB-BSMT
BASEMENT >&
1sT FLOOR
2"°FLOOR
3RO FLOOR
401 FLOOR
5T"FLOOR
6T"FLOOR
7T"FLOOR
8T"FLOOR
Installing Company Name crp �n7sioO pili
i2 Check one:
Certificate /
Address F77e--.4-4t42 (ti/ cockoration �Sf
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c---5/ Ye ,; 4 // 0266/ in Partnership
Business Telephone# ')TP) Y 'I
/�' ?/ 77L`& �f �) 0 Firm/Co.
Name of Licensed Plumber or Gas Fitter NS �'L'�/ _e/) '/tea jtSikeCJ
INSURANCE CO RAGE:
I have a curre iabiiity insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. ^ /)
Yeti No ° yd ACCEPTED / /
If you have checked y✓s please mate the type coverage by checking the appropriate box.
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A liability Insurance policy Other type of Indemnity 0 Bond o BY: ;
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 oye:
Owner a 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 ove applies' n are tr an accu to to the b f my
knowledge and that all plumbing work and Installations performed under the permit Issu r th plication ail e I mpliance I
ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General I.
By Type of License:
•-Plumber
•Gasignature of Licensed Plumber or Gas Fitter
Title erer
••Joumeyman
•�vtaster License Number
% �
City/Town
APPROVED(OFFICE USE ONLY)