HomeMy WebLinkAboutG-12-162 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
E a"3/.__� City/Town: 9R/einatJT�1 ,MA. Date: 9/� '-4 Permit/412-16 Z
Building LocationuSto Root- !31_/QA..0 A Owners Name:al 1F1.5olF
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GType of Occupancy: Commercial 0 Educational ❑ Industrial ❑ Institutional❑ Residential
New:❑ Alteration:0 Renovation: ❑ Replacements Plans Submitted: Yes 0 No❑
FIXTURES
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51"FLOOR 3Y
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7'"FLOOR
8'"FLOOR
Check One Only Certificate#
Installing Company Name: E77/44NSL ____/il/G' .
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C
orporation SacP/C
Addresst9ac142,j_I &ZCCity/Town: t / f14JI1I/T// State: /14-
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0 Partnership —
Business Tel: 5-08--397-777er Fax: 3a
€9026%p A ❑Firm/Company -
Name of Licensed Plumber/Gas Fitter: .. /a pyeA/ /f- `l/,,isz ji
INSURANCE COVERAGE:
I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 Yes tNo 0
If you have checked Yesplease indicate the type of coverage by checking the appropriate box below.
A liability insurance policy Pf 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
Owner ❑ Agent
Signature of Owner or Owner's Agent
By checking this box 0;I hereby certify that all of the details and informatio i ave submitte (or ente • egardi g this :.. ation are true and
accurate to the best of my Knowledge and that all plumbing work and installa •• •erformed un•-r t. , per it I •ed fo -pplication will be In
compliance with all Pertinent provision of the Massachusetts State Plumbing Code an. .•.•ter 42 •f the en :I Law
Type of License:
By 0 Plumber
Title ❑Gas Fitter Signa ure of Licensed Plumber/Gas Fitter
Master /y
City/Town ❑Joumeyman /License Number: 2a 9Q
APPROVED(OFFICE USE ONLY) 0 LP installer