HomeMy WebLinkAboutG-11-467 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
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it Y ��'►i/�/r/h Mass. Date �— 0S 20// Permit,/ 6(-- 617
Building Location mi . etA nnrr,Ath Owner's Name /"`'" / e,„ , ' 4o")
Owner Tel,/ cB -891)-YQS
7 5 Type of Occupancy
New a Renovation 0 Replacement Plan Submitted: Yes a No 47
FIXTURES
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SUB-BSMT
BASEMENT I
1sT FLOOR
2N0 FLOOR /
3R0 FLOOR
4TH FLOOR Voir
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ST/4FLOOR r" ,OR..''''"'^"'rr
BT"FLOOR G t•�+R' MOP
7TH FLOOR
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Installing Company Name gre,o/2-IO/L) p4tI A Checkckone: Certificate /�
Address G0 F41AQ/ (3L 6/t fal' SjS1 l�
c5, 3Ori_n6(u/�h2/�' /�4_ 0264/ a Partnership
Business Telephone# �!1 CJ0Y" -7 778 /� ❑Firm//Co.
Name of Licensed Plumber or Gas Fitter NT/cep/74i) g •tai S,hL)
INSURANCE CO RAGE:
I have a curre lability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142.
Yes No 0
If you have checked y✓please icate 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
OwnerAgent 0
Signature of Owner or Owner's Agent
I hereby certify that all of the details and Information I have submitted(or entered)in a••ve appli; on are true a accu.. e to the bes AV
y
knowledge and that all plumbing work and Installations performed under the permit Issu-• or 't'-'application wi :, n / Mimeo wit :J!�"
ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General s.
By Type of License:
-Plumber Signature of Licensed Plumber or Gas Fitter
Title •Cas fitter ,iJ��„q
••iFAaster license Number eb g)
City/Town ••Journeyman
APPROVED(OFFICE USE ONLY)