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Home My WebLink AboutG-11-779 „I. c , . MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING = City/Town: / grttSo4�ti MA Date: S\11• �11 • Permit GI '117 . Building Locaticn:30c 4WCk tS ca n 4. vSc Owners Name:1 c t S G. gQta,%h G Type of Occupancy: Corr:mercial❑ Educational❑ . Indust ai❑ Ir..s;tuticr.af 0O Re&dential New:❑ Attention:❑ Renovation:❑ Replacement:121 Plans Submitted: Yes❑ No m CuNS\t . 1we a.l .. FIXTURES . cn vi W C M H til F- rn 2 M • VI I 2 W 0 t7 _J Y 2 t- .. . N O z W C CC 2al O Z g z 0 2 FW- . 2 IC C O Q o N W W u1 O O p, it•I C > U W Z V' -i <LU ILI I- Z p = 0 It y — W W W w 0 2 M D s tC u! w Q m > O z O W 2 2 14 i2- U ii 0 4. 0 0 2 2 .-1 O o, , M M H = > > 3 O SUB BSMT. BASEMENT • 14' FLOOR ' fL FLOOR I ” . r-FLOOR • • 4'FLOOR 5'FLOOR . • II ' 71"FLOOR I - 81"FLOOR I ' I I I Installing.Company Name�7' E M \\ Ste r c%C is \ht., Crock Cre City Cer if care �\e•t1 dna, 11 � (� ©Corcntlon 2% �c1 AddresaNS.w�e`\xw.`'Ton `t.a, CtyrcwnLwnCo\n State:—t 0; 0 Partnership • ' Business T alMol F,3S L\eS 41 Fax: 0 Finn/Company Name of Licensed Plumber/Gas Fitter.Cr24'.rtCk `CO a i:no,'rn • INSURANCE COVERAGE: • I have a currant Babitltr insurance pcllcy or lb subsbntial equivalent which meets the requirements of MGL Ch.142 Vest No 0 If you hays checked Yas. please Indicate the type of coverage by check7ng the appropriate box below. A liability insurance policy 2 Other type of indemnity 0 Bend 0 CWN=R'S INSURANCE WA:VER:I am aware tat the licensee does act have the insunnca coverage recurred by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit applicator wolves this requirement Check One Only Owner 0 Agent 0 S Brat re of Cwrer or Owners Agent By checking this box M :t hervty urt1f that ad of the details and Intonnancn I have submitted(or entered)regarding thia application are true and accurate to the best of my Knowledge and that all plumbing work and Instalattdns performed under the permit%sued for this appgcation will be In compliance with all Pertinent provision of the Massachusebs State Plumbing Cede and Chapter 142 of the General Laws. Type of License: �{ 1 e """`^--� BY l Plumber C-� , OW arae 0 GastFiar Signature of Licensed Plumber/Gas Fitter Ct/fl m ❑Joumeyman License Number. G Z-� APPROVED ICF?ICE USE ONLY) 0 LP Installer .--- .... a 1101.IJ3JS1}I1.111111.11SVO • - r. - - - A' • 3 • ` -- . 7,::1 • ._ - ?.1 I . _l ii i I. I ., ti , e. 3LVA 0031NYNJJJHV113J - , 1, $ • 1 1 ,t . , . - I @1311110N 3SN1311 • ' -' j j , 2 . t iI1313NS - • DN10111Tt1 JO116S1V001 - I. r ! - b}11U71f1f1403JAL,H1VV11 • . ` _ ' t • 4 ! . _ i ONlld.IJ SVO OA 011114013J801 KOLLVJl1J1V - - • 1111111]) - S :311 t. ;P• 1 • 1 (S}N01121.1S111 SSa1}n0111 M 1t10 aSN F131:110'801 MO-131] NO11O3JSN1`1MA1! ¶ •.i - - 4, _