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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type) C 2
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DateIL-22_20 1 Permit#r47/ -,- ,72--
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—' I � �Ql er•sName
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?_ —A.,y Building Location
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Plan Submitted: Yes 0 No �Y'
New ❑ Renovation ❑ Replacem Fl1TURES /
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SU -BSMT
BA EMENT
1•TFLO R
2N°FLOOR
3"o LOOR
41"FLOOR
5Th FLOOR
6Th FLOOR
7T"FLOOR
8T"FLOOR /1
frFG��//Iskio Ali `-`) Check one: Certificate
Installing Company�jName %'� /� v � �� fy / /
Address 0 RP 4Ft ' 4, (f/t orporation 2i! C_
'l 1i o966/ ❑Partnership
Business Telephone# 573R tom/ 7 7 7 7/3 /� ^ / ��5
Name of Licensed Plumber or Gas Fitter -SW h/0 e• / /71 Nl t
INSURANCE CO RAGE:
I have a curre iabillryNo o Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142.
Yes
If you have checkedees,please tate 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.
•. :r : gent ❑
Signature of Owner or Owner's Agenti re Wean• e to • _ •est of my
I hereby certify that all of the details and Information I have submitted(or entered)In abov: .pp hca!9n
knowlge and that all plumbing ertinentt provisions of the Massachusetts setts State Gas Code end Chaprk and Installations performed ter 142 •er the the General Laws.
rmit issued fo ..a ap• aeon will •_ • Oa ..-wit. .'
By Type of License:
•'Plumber Signature of Licensed PlumberPleror Gas Fitter
Title •Gas fitter
11)
.'Masterer
License Number /�.z4
City/Town •Joumeyman
APPROVED(OFFICE USE ONLY)