HomeMy WebLinkAboutG-11-691 "In
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
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Q?. . =eL Y f/710 tAtii 'Sz/7, ass. Date (91/45-20 // Permit#W I ' 611
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„ Building Locations l3' - /e Owner's Name G� bat
.. Owner Tel# 701' S'72- 4J baa Type of Occupancy wS /
New 0 Renovation ❑ Replacement 19' Plan Submitted: Yes 0 No1
FIXTURES
745/- 5 _ -/ II
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3c37 / E
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SUB-BSMT
BASEMENT I _ ,
1ST FLOOR
2H°FLOOR
3RD FLOOR
4Th FLOOR
5Th FLOOR
6Th FLOOR
7Th FLOOR
•
8Th FLOOR r - /
Installing Company��oj'' Name Erji(u/4sJOLO pH) (_2 Checkckone: Certificate /�
Address 2% �E4&412 4€, /t / t3•Corporation 37S/ l_
c��/1 i��N/5 ,Mg c964/ 0 Partnership
Business Telephone# �C7 X V it ///7 7LL13 ,/� 0 Firm/Co.
Name of Licensed Plumber or Gas Fitter SY-- ph-e/) g •GL2/i9s,Y'L)
INSURANCE CO RAGE:
I have a cure iability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142.
Yes No ❑
If you have checked yes,please mate 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.-:
Owne - Agent
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered)in a rove applicatio; are true. rate to the•• t of my
knowled•e and that all plumbing work and Installations performed under the permit Issue. • ication w' wr,y•mpliance /h all
seta rovislons of the Massa ,usetts State Gas Code and Chapter 142 of the General L. . : /
137 if$0.V117411F Type of License:
/l ••Plumber Signature o icensed Plumber or Gas Fitter
Title 1 k 5 Kn ,, •
Gas fitter /J
"fa
(J� •4vlaster License Number ��n1
City/Town l�celTOlJ-J1 . •'Journeyman
APPROVED(OFFICE USE ONLY)