HomeMy WebLinkAboutG-11-832 -:
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
, = „+ City/Town: �— PO V-+ �1 ii Permit# a a 3a
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=t[s MA. Date: 6/
Building Location: 13 Covey 0e ' Owners Name: 71-118077-
GType of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional 0 Residential .
New:0 Alteration:0 Renovation:0 Replacement: a Plans Submitted: Yes 0 Noel
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FIXTURES
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SUB BSMT.
BASEMENT
1s' FLOOR
2Ne FLOOR
3"O FLOOR
4'"FLOOR
5'"FLOOR
6'"FLOOR
7'"FLOOR
6'"FLOOR ,,//
InstallingCompanyName: j 0 CIC I<Q YI( Check One Only Certificate#
Address:3 o ry e Iiia \ M 0 Corporation
9171 y R4 City/Town: S- 7 q row% State: / r cf •
Business Tel: 3 C/ / c2.9 as- ❑Partnership
Fax:
[b].Firm/Company
Name of Licensed Plumber/Gas Fitter: Jq tic. ((q h C.
INSURANCE COVERAGE:
I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142 Yes[4rNo 0
If you have checked Yes,please indicate 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 waives this requirement
Check One Only
Signature of Owner or Owner's Agent Owner 0 Agent 0
By checking this box 0;I hereby certify that all of the details and Information I have submitted(or entered)regarding this application are true and
accurate to the best of my Knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be In
conce with all Pertinent pro./(on of the Massachusetts State Plumbing Code a d Chapter 142 of the General Laws.
t�is__,�, IA „tris N., Type of License: /
�7Plumber deli
Title ka Mas Fitter Signatu I :nsed Plumber/Gas Fitter
\/ 0 Master
city Town C) J L loumeyman Licens' 1 amber: aa Z SS s
APPROVED(OFFICE USE 0 LY) 0 LP Installer