HomeMy WebLinkAboutG-11-763 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
G:I I /MIMI& ,Mass. Date 574' 20 f/ Permit 4.l( — 74, 3
Building Location �j y agog/ SI r Owner's Name /7k� �lly
Owner Tel# Sob—NY-6611- Type of Occupancy Ado
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New 0 Renovation 0 Replacement Plan Submitted: Yes lo No
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SUB-BSMT
BASEMENT I
1ST FLOOR R E G I '
2ND FLOOR _
3RD FLOOR MA? 05 2011
. - 4'"FLOOR , ..
- - - 5"FLOOR - , .. "' BUI-DING L EP.
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7TH FLOOR - . r.
8'"Ft.00R • • -,R n
Installing Company Name isry. 15 TWG -.- Check one: Certificate
Addressall2 f'li1d—Tec/.' Oni/t - 7.(Corporation 1762. 0
War VOsempal, MA '02473 ❑Partnership
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Business Telephone# 5-01?"—775-- 1303 ❑ Firm/Co. .
Name of Licensed Plumber or Gas Fitter FRANK. W: Roder7CK -
INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142.
YesNo ❑
If you have ACecked •Les,please indicate the type coverage by checking the appropriate box.
A liability Insurance policy 7(..
Other type of Indemnity 0! _Bond ❑ -
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 one:' -
. . -. Owner 0 Agent a
Signature of Owner or Owner's Agent -. , - ,-'- -_. - - • --' ' I
I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my i--
knowledge and that all plumbing work and Installations performed under the permit Issued for this application,will be in compliance with all I ,
.eL� rovisi.n• • 'e s- husetts'State Gad Code and Chapter 142 ofthe:GeneralL s.-'/I,,, r 1 ! 1
1 �I v ,! .Type
___I.,L Signature of Licensed
Plumber or GaslFitter-.
I I —
BY i\ Yf1t� �ire�}� -I T e of License � I-.. 1 . Ln " W.--mat 'v,yy�; •.._ +- _.
Title e ••G_as fitter 1 779„
-�' �nrMaster , License Number - -
Cityrrown 1 • . Hyman _ •
APPROVED(OFFICE SE ONLY)