HomeMy WebLinkAboutG-12-262 Unit 503 •
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
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ED----_____MM-_il t✓• yOnt oik ,Mass. Date 1/2- 20 /I Permit#U II 2 -�//9(P
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, l Building Location 351T L 4f ST•- t'l em- 4 SVSOwner's Name i/� Ghrnft
Owner Tell W7-247-4'223 Type of Occupancy 1 LIit ,,, U
M New ❑ Renovation 0 Replacement Plan Submitted: Yes ❑ No }<
FIXTURES
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a a BJILDINGDEPT1wNw z O o
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SUB-BSMT
BASEMENT I
1° FLOOR
2N0 FLOOR
3RD FLOOR
-S 4'N FLOOR
: -S.x FLOOR. .
_ ..`. • 6TH FLOOR - _
7T”FLOOR .. . .. _. .
. 6T"FLOOR n
Installing Company Name • RNST'y/S INC. Check one: Certificate
Address aA2 Mid-Tall On✓t I'KCorporation 1742C
War YOvrq&-117_. MA 02472 ❑Partnership
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Business Telephone# SDS-77c— 1303 0 Firm/Co.
Name of Licensed Plumber or Gas Fitter Ft/WK W; Wend<
INSURANCE COVERAGE:
I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142.
- Yes No ❑
If you have flecked y—es,please Indicate the type coverage by checking the appropriate box.
A liability Insurance policy 7( 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.
Owner ❑ 'Agent ❑ _ '
Signature of Owner or Owner's Agent .. .- - i .
I hereby certify that all of the details and information I have submitted(or entered)in above 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'.
ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. /` r " " ' ' - . "" , .
By - Type of License:. .. . . . PVA W. "f dC-- . . •
••*Plumber Signature of Licensed Plumber or Gas Fitter ' ,
Title ' •Ga fitter 779'f
License Number
City/Town • ..rneyman
APPROVED(OFFICE USE ONLY)