HomeMy WebLinkAboutG-12-082 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
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II? r°L=0f a4M ��th ,Mass. Date Gr Va 20// Permit kis t (–II–Vic-
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B` M Building Location /5"L ra,07L Mace ,4'C Owner's Namegafl/X ( `2l2/7,-
°c.;;; • Owner Telt .5'/Ll re//-7 i Type of Occupancy -/S -
New 0 Renovation 0 Replacement 04-------7
`--/ Plan Submitted: Yes 0 No ❑//
FIXTURES ,Y
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SUB-BSMT
BASEMENT I
1°T FLOOR
2ND FLOOR .
8R°FLOOR .
4T"FLOOR .
5T"FLOOR
• 6T"FLOOR
7T"FLOOR .
8T"FLOOR //
Installing Company/oName Ei-i.'t//7s/L)/() �-/7 (, ) Checkckone: Certificate /
Address 0 �P-/�E4l/9 ('31( t / / p^Corporation .&S/ CL
c5, 3/evin;�A% Mn 0,166/ ❑Partnership
Business Telephone# -� )P) 5'4 ¶17/ )77a �) 0 Firm/Co.
Name of Licensed Plumber or Gas Fitter v -_e/) i2 •/12 0...s rt 0
INSURANCE COyERAGE:
I have a curree lability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142.
Yes No ❑ •
If you have checked des,please irate the type coverage by checking the appropriate box.
A liability insurance policy 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.
Check o
Agent -
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered)in abo applicat' re true a d ,• u-:te t•the b- t of my
knowledge and that all plumbing work and Installations performed under the permit Issued fo ap cation wi b= •mplia ce •th a
ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By Type of License: (/
•'Plumber Signature of Licensed Plumber or Gas Fitter
Title •Gas � /J.f—/Jb
•FMester er License Number / j
City/Town •"Journeyman
APPROVED(OFFICE USE ONLY)