HomeMy WebLinkAboutG-11-841 .. , -
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
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VV. rOWD'A� ,Mass. Date 4/13 20 I I Permit to I I/-g LI / r
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ltm Building Location Soln likek f ( t'lal Qin-St .Owneis Name S gay /A pitt
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..s"•. Owner Tel# 50--574—Iv ' Type of Occupancy /ttrI""WV
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New 0 Renovation 0 Replacement 0 Plan Submitted: Yes 0 No 0
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SUB-BSMT
BASEMENT -
16r FLOOR
2N0 FLOOR
3HD FLOOR
- 4T"FLOOR
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I_..,, -'• - 51"FLOOR
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._..__ 7r"FLOOR
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I Insla11impanyNarrie— RNS'!yIS- C
r Co • • '"Check one: Certificate
Address -.PA2 -Mid-TCcl1 On✓c - Corporation 1742 C
• -- War yantua 1, MA 02473 ❑Partnership
Business Telephone# SOS-775— /303 0 Firm/Co.
Name of Licensed Plumber or Gas Fitter FRANK W: Roderick.
INSURANCE COVERAGE:
I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142.
Yes No ❑
If you have Acked y ,please indicate the type coverage by checking the appropriate box.
A liability insurance policy / ' Other type of indemnity 0 Bond ❑
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 one:` .. -
_- _..
- _ Owner ❑ Agent. ❑ .. _( . f._. 1- I
Signature of Owner orOwner's Agent ;-,- - -- '-T
I hereby certify that all_of thedetails and information I have submitted(or entered)in above application-are,true and accurate to She best crispy., ;,.....I
knowledge and that all plumbing work and Installations,performed under the permit issued for this application will be in compliance with all I : I
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General La' I { , ,----1---,- ,,
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By - � Type of License i _ -- _ 1
i• - r Plumber Signature of Licensed Plumber or Gas Fitter :
Title `. s ftter.
- - efeMastes) License Number- 7791 -
City/Town --- •quffineyman
• APPROVED(OFFICE USE ONLY) . . -