HomeMy WebLinkAboutG-12-253 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
17-'1= r ci crown: \lar i'll ,MA. Date: 1012.e/2011 Permit#G I2 —2 S3
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Building Location: 17 Cama el 2,4Cou 12i) Owners Name: tAa1n40Lo4- , zo t 6,^4
Type of Occupancy: Commercial❑ , Educational 0 Industrial 0 Institutional 0 Residential Er
New:17 Alteration:0 Renovation:0 Replacement:0 Plans Submitted: Yes 0 No❑
ou6.44643 2 S+ l0-311--1 t ICAC. FIXTURES
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2N° FLOOR
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418 FLOOR
5'"FLOOR
6'"FLOOR
7'" FLOOR
'8'"FLOOR
,% Check One Only Certificate#
Installing Company Name:go Pi IFS rEFRttEIZR1'101i iMit
W` IS9
/ 11 Corporation
Address: al4 iHitMWODZil tpurf. City/Town: WPriJNIS State: MR
OSLgO I 0 Partnership
Business Tel: SOS-T75-3023 Fax: 508-?40 _pg 34
0 Firm/Company
Name of Licensed Plumber/Gas Fitter.
INSURANCE COVERAGE: � //
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 Yes Od'�❑
If you have checked in,please InQIcate the type of coverage by checking the appropriate box below.
A liability Insurance policy [1p/ Other type of Indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER:lam 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 ❑ Agent 0
Signature of Owner or Owner's Agent -
By checking this box U;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.
Type of License: if i
By . 0 Plumber .. r . t s - i, i., ' '
Title ❑Gas Fitter Signature of tensed Plumber/Gas Fitte
❑Master 5'S'
cCity/Town 7 City/Town ❑Journeyman License Number: 7
APPROVED(OFFICE USE ONLY) 0 LP Installer .