HomeMy WebLinkAboutG-11-632 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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Ca"'"l;._- ' CitylTown: r 20 MA. ate• 3 —16 — I/ Permit#G)k—& 3 2-
v Building Location: 243 &c A 4 Owners Name: VffS°'r'4 '2 e de-, c NA
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GType of Occupancy: Commercial 0 Educational 0 Industrialia0 Institutional 0 Residential
New:0 Alteration:0 Renovation: 0 Replacement: ll'I Plans Submitted: Yes 0 No)
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151 FLOOR 1
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4".FLOOR
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�jLinl 6 Check One Only Certificate#
Installing Company Nam:: Ur r�^�11 ,�►`t It e
❑Corporation
Address: - / ' City/Town: J.k. 17/7 r S State:
Partnership
Business Tel: Pi-77 STA Fax: 4. irm/Company
Name of Licensed Plumber/Gas Fitter: C 4 R M(' l4-C V
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes 0 No❑
If you have checked Yes.please Indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy Other type of Indemnity 0 Bond 0
OWNER'S INSURANCE WAI R: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
Signature of Owner or Owner's Agent Owner 0 Agent 0
By checking this box 0;I hereby certify that all of the details and Information I ha submitted(or entered)regarding this application are true and
accurate to the best of my Knowledge and that all plumbing work and installatl•ns i rfonned under the permit issued for this application will be in
compliance with all Pertinent provision of the Massachusetts State Plumbing Ctde an,` hapter 142 of the General Laws.
B QQ�L Type of Lleense: -a'
i ❑Plumber
� "" ❑Gas Fitter
Title 1 Wspyra v,�. 0 Master Signature • • • umber/Gas Fitter_
Cityrtown > w n ,, cyuZ ❑•loumeyman License Number: ) 9;
APPROVED(OFFICE USE ONLY) 0 LP Installer