HomeMy WebLinkAboutG-11-576 . 6, (oD
• MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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City/Town:YLtrml7)Jy�, MA. Date: A 1 i I Perm Ft# �+� �7.
Building Location:1&9got k --cA)"'v P.A. Owners Name:VIA�) 11Ay4, Arft'(S
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Type of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional 0 Residential
New: 0 Alteration: 0 Renovation: 0 Replacement: Plans Submitted: Yes 0 No [[]---....---
FIXTURES
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SUB BSMT.
BASEMENT
1" FLOOR � I
• to FLOOR' ' 1
3Ku FLOOR • . ' .
41"FLOOR _
5'"FLOOR
•
61"FLOOR .
7'"FLOOR
8'" FLOOR .
Check One Only • Certificate# •
Installing Company Name to*
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�' (k 64 y /
i , t/ ��/ J Corporation ] C
•
Address:__ f •�.Ile A City/Town: Yarf/lfJ(Jt"1‘ State: i
I 03601 0 Partnership
Business Tel:c-$' _3qs ,l Fax: ..13,-'/(2/1-.0.661
y��"I�r,� ❑Firm/Company .
Name of Licensed Plumber/Gas Fitter: Scfl4 V` tU le- CO- • •
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INSURANCE COVERAGE:.
(have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 YesNo❑
If you have checked Yes,please indicate the type of cbverage by checking the appropriate box below. '
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
...Massachusetts General Laws,and that my signature'on this permit application waives this requirement
Check One Only.
' • Owner 0 Agent 0 •
Signature of Owner or Owner's Agent •
By checking this box 0;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 installatiohs performed under the permit issued for this application will be in
co�,,,,.nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. -
By 1*'' T/r�TIMI
j' Type lcense: /S .
•
lumber
Title
. S Lmastercl r Sig - re of Licensed PlumberlGas'Fitter
aster
City/town Sagl�� ['Journeyman cense Number: f5/y�
APPROVE (OFFICE USE 0 LY) ` 0 LP Installer