HomeMy WebLinkAboutG-11-623 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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t: ',=s, ty W "1 OIYMO U't}l ,MA. Date: 3 -)--)1 al ( — 62-3
-.M;ag_:,` CI /Town: 1 /� Permit#) 1-
Building Location: 3 10- CA hl 10 .St'` Owners Name: We 1 G!'
GType of Occupancy: Commercial❑ 1 Educational 0 Industrial❑ Institutional 0 Residenti,LE'
New:f2<Alteration:0 Renovatiyo�n:0 Replacement:0 Plans Submitted: Yes 0 No,p
1 , 1 Re-.grisf-d e— 3/7/i f`FIXTURES
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SUB BSMT.
BASEMENT
1°1 FLOOR X X
2""FLOOR
3""FLOOR
4'"FLOOR
5'"FLOOR
6`"FLOOR
7'"FLOOR '
8'"FLOOR
t Check One Only Certificate#
Installing Company Name: coy ho pips
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0 Corporation
Address: f'V/r/f v$ 1 ca i 1 City/Town: -fit rid Val State: m f ,
0 Partnership
Business Tel: 11 4- a-bc1- 9-197 Fax:
Firm/Company
Name of Licensed Plumber/Gas Fitter: my /o IYNCS
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes)26lo 0
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 ❑ Bond 0
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
Signature of Owner or Owner's Agent Owner ❑ Agent 0
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 Installations performed under the permit Issued for this application will be In
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
T pe of License:
By Plumber
Title (N5p` C-f-E�_ 1 .a6is Fitter Signa Vre of Licensed Plumber/Gas Fitter
❑Master
City/Town �14t2IA4 °GM& 2meyman License Number: 3g
APPROVE (OFFICE USE ONLY) 0 LP installer