HomeMy WebLinkAboutG-12-393 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/Town: year^t1lUVfA MA Date: lAid.l /i-0/$ Permit#r./7i 317
Building Location: /, City e 11 n C LOA/C Owners Name: hiG19r y .-T Cons
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Type of Occupancy: Commercial 0 Educational 0 Industrial 0 institutional 0 /Residential E'
New:0 AReration:0 Renovation:0 Replacement Er-' Plans Submitted: Yes 0 No 0
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1"FLOOR
2re'FLOOR
31°FLOOR
4'"FLOOR
S'"FLOOR
6'"FLOOR
7'"FLOOR
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Installing CompanyppJJi// � Name: ,/sst/f Ft gCheck One Only Certificate#
Address: thv sit City/Town:*mete State: 41 0 Corporation
Business Tel: Snag? S/> Fax: ❑Partnership
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Name of Licensed Plumber/Gas Fitter. 7/p- K Firm/Company
44 sserr
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 checked yis please Indic the type of coverage by checking the appropriate box below.
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
Massachusetts General Laws,and that my signature on this permit application want,this requirement.
Check One Only
Signature of Owner or Owner's Agent Owner 0 Agent 0
By checking this box a I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and
accurate to the beet of my Knowledge and that all plumbing work and Installations performed under • permit issued for this application will be In
compliance with all Pertinent provision of the Massachusetts State Plumb Coda and C a
• 1 of the General Lowe,
Plum
By or License:nae:
ber //'0
Title Brr
MaFitter Si r na e • icensed Plumber/Gas Fitter
City/Town ❑Journeyman License Number: //Gf.2
APPROVED(OFFICE US!ONLY) 011 LP Installer