HomeMy WebLinkAboutG-11-468 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
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f• * 11 c I A'' `` d U 1iass.Mate 20/ f Permit# 6 I (-4(0O
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�°- = 4 Building Location 3gB O`F i t A N b Owner's Name JO ft 0Q S, I" V 'G/ So-
` ,. Owner TeL a $ • 78 7. 9 & 7 0 Type of Occupancy / —
New 0 Renovation 0 Replacement^4 Plan Submitted: Yes 0 No•L
FIXTURES
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g 0 C0 x R 0 3 o c� S u a > o n k' 8R
. SUB•BSMT _ /
BASEMENT `X
1•T FLOOR
2N0 FLOOR r
3R0 FLOOR
4TM FLOOR t
5TH FLOOR ACC141 L?
6m FLOOR R,r• ....��'—"" I
7TMI FLOOR
BTM FLOOR T / /y
Installing Company Name Era�/17sk& pH /_O Check one: Certificate C.-
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Address CJ T?rAs ' (IC t l t / / 4orporation SjS/ 1.
„5, 3/I/ fl6IN* 'ii g 09661 ❑Partnership
Business Telephone# -TA ::54 ¶ -7
77L3 /J ��tL.���� 0 Firm/Co.
Name of Licensed Plumber or Gas Fitter •S ,O,17-€i) `� • 1i 51;60
INSURANCE COyERAGE:
I have a curre lability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142.
Yes No a
If you have checked y please mate the type coverage by checking the appropriate box.
A liability Insurance policy. 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
Mass.General Laws,and that my signature on this permit application waives this requirement.
• ner .r. Agent •
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered) :•• e applic. '"i. are true and a rat: • he best of
knowledge and that all plumbing work and Installations performed under the permit issued fo •Is':plication will be' co.I'.nc with all
rtinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General
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By Type of License:
••Plumber Signature of Licensed Plumber or Gas Fitter
Title •Cas fitter i/
�
Raster License Number .f—�
City/Town •Journeyman
APPROVED(OFFICE USE ONLY)