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• MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTINGPairS
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- t1 rr'' r>l3Q/e Permit#L(4 7,7Jr
ltd € City/Town: �. YL�m`y/ MA. Date:
� ". Building Location: go()gKte ,ny p t Owners Name: f[44/7 r /t
s 5 Type of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional 0 Residential 0
`��r New: 0 Alteration: 0 Renovation: 0 Replacement: 0-" Plans Submitted: Yes 0 No ❑
FIXTURES
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SUB BSMT. l
BASEMENT l f
1" FLOOR
2"FLOOR' ' '
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3"u FLOOR • J .
• 4'"FLOOR •
5'FLOOR
• • 6'1'FLOOR
7'"FLOOR I C ' •
8' FLOOR I ,
�,y�,, �`�,.,,^ ]�� Check One Only • Certificate#
Installing Company Name: '1" ` v„'i TCQ �A tCo-)lf�
�r� /� , aeorporation
Address: S I LAME {4\ City/Town: ` ,n't1_il'j State:414.
Cel( E Partnership
Business Tel: -.s378-6961 f„t.- 3:g-g6d'-sa77
�–�^ ❑ Firm/Company
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'Name of Licensed Plumber/Gas Fitter: V k Yenhvsoi •
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes-Eno❑
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy Er". 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.
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---"` -- — ' Check One Only.
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Signature of Owner or Owner's Agent Owner 0 Agent 0
By checking this box❑;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 provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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By
, Type of License: -
DiatTmber <'
Title . . •
❑Gas Fi r Si• r- re of Licensed Plumber/Gas'Fitter.
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City/Town ❑Journeyman '- ense Number: t/2-
APPROVED(OFFICE USE ONLY) 0 LP Installer