HomeMy WebLinkAboutG-12-288 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
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* yi,,��/J h ,Mass. Date'/F/`" 20 // Permit# a "n gE
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i— + Building Locationlb Owner's Name
%,"e.: • Owner Tell/ ;S -MO, go/ 9 Type of Occupancy 05
New 0 Renovation ❑ Replacement Plan Submitted: Yes 0 No ,/'
FIX URES 7
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111
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1•--fr _ it' BASEMENT
1"FLOOR
2Ne FLOOR
er'FLOOR
41"FLOOR
51"FLOOR
5Th FLOOR
71"FLOOR
5TH FLOOR
Installing Company Name / Check one: Certificate
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Address CJ J71-41eAO [ 3€(1It olporatlon
Gr j/&fl p;ill*�7, /l4 09661
-79 66 /1 a Partnership
Business Telephone# 57)P) ---6Q 11 7 7 it /n1 •
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Name of Licensed Plumber or Gas Fitter S'ITph-?/) i ✓ •/^�/1/—'�""'�
INaURANCE CO)+ERAGs:
I have a acre ability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142.
Yes No D
If you have checked Yea,please cats the type coverage by checking the appropriate box.
A liability Insurance policy Other type of Indemnity o Bond o
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., k o•-:
Owner = Agent O
Signature of Owner or Owner's Agent re true an• .• u e to the • of my
I hereby certify that all of the details and Information I have submitted(or entered)In above api Vct�fIi tote all
eNnentt provisions of thelMassachusetts Staterk and iGtions performed as Code and Chapterr11 •of the General armit Issued for this e;• c tion will •= p
13 By Type of License:
••Plumber Signature of Licensed Plumber or Gas Fitter
Title •Gas fitter ` ,ys y
.Qdasler License Number /
City/Town ••Joumeyman
APPROVED(OFFICE USE ONLY)