HomeMy WebLinkAboutG-11-819 1,,
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Prim or Type) t I �+ p
Q?"Wil el - UAR-f10U1t(Mass. Date c• � 20 ,7 Permit#G I( - 0 19
►iN v l *Si 131) 4t IA N_6 Owner's Name 5p It! 3 Nrity
Building Location
VN `� to • oG r
e t t%,tJ Owner TeU! (� Type of Occupancy I\'C.S •5 `4"/ P�
So $°..afi0 ra0/9 ,
New 0 Renovation 0 Replacement`� Plan Submitted: Yes ❑ No ❑
FIXTURES
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SUB-BSMT -
BASEMENT
1°T FLOOR
2M0 FLOOR
3R0 FLOOR -
4T"FLOOR
5'FLOOR .
6"FLOOR - .
7"FLOOR , - -
5"FLOOR / / /�
Installing Company/oName E`i1�i'/2s/Oiij Ali t2 Checkckone: Certificate/
Address e) TSE-4,,ede0 (31 e t / / e Corporation Zee CL.
3/�lv]i;ut */7'//x147 c72(r 4/ ❑ Partnership
Business Telephone# ,'jTP) -%.50(I - 77& �) ❑Firm/Co.
Name of Licensed Plumber or Gas Fitter SW/oh-et) 4 • / /i7S,/7tL)
INSURANCE CO RAGE:
I have a curre ability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142.
Yes No 0
If you have checked •Les,please cafe the type coverage by checking the appropriate box.
A liability Insurance policy Other type of indemnity o 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.
Check opa
c,merx•T - Agent •
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered)in -•ove ap•li •A are tru• •nd :•• rate tot - •=sl of my
kn• - ge and that all plumbing work and Installations performed under the permit issue. •r I :ppllcation ill •• compile�- , I =II
.e-,i.ravish s •�,.e Massachusetts State Gas Code and Chapter 142 of the General ,��J
By \4 Ji&1v lI r_ Type of License: A.%`�
•'Plumber ignatu -of Licensed Plumber or Gas Fitter
Title 10 C % C ••Gas fitter 1 �1iy
/� •2Master Ucense Number / '
CI iTown`1 c�—� 0 • •doumeyman
APPROVED(OFFICE SE ONLY)