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HomeMy WebLinkAboutG-11-701 -- • MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING -' I —car _,^. 3 CitylTown: '}IAYMf71kh MA. Dater_ PermFt# C�( "75 1 ter , Building Location: lit •'tci it Owners Name: PG n , ' ' Type of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional 0 Residential [R— New: 0 Alteration: 0 Renovation: 0 Replacement: p— Plans Submitted: Yes 0 No❑ FIXTURES • Co EU LU W co ce N re Q ' 2 CC N co = y in D • O. W W U m h- to O g w a • Z z cd I- 01 li. V r ow u to 0 G Z F- O W rn W m O ¢ n. t_ t] tv W x . [C t co O W w .cc O = rn W F p it ,� W Q C7 J W z .co W co 2 Z WVC C • . U W Z I- F- OO z J 0 LL W F- W W U O .O Lt. OU` QO` w 2 J O 6O. fY 0 tu Z Z j ~O !RECEIVED SUB BSMT. ApR 1 2011 1 BASEMENT I • I • 1" FLOOR NU I BUl0.UIN Pi. 2 FLOOR e,3HO FLOOR • ' 4'" FLOOR . t • 51" FLOOR _ • _ • • 6r FLOOR • 7'"FLOOR 8'"FLOOR ' �,i��,1-- � Check One Only . Certificate# • • Installing Company�FNamer�YlYfl�TYf! �y5 /ett Corporation �C • Address a ' 1 •�1'�s � CitylTown: y4rr/F ik State:Mp t I CPU 0 Partnership Business Tel:c1: -3q9-96701 Fax: .5-6 ribo-ipte1 p tom, ' ❑Firm/Company Name of Licensed Plumber/Gas Fitter: Ic fV V�SCO- • INSURANCE COVERAGE:. • • I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YesNo 0 If you have checked YJ please indicate the type of cbverage 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. ' Owner 0 Agent 0 • Signature of Owner or Owner's Agent ' 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 com• anccee with all Pertinent��provisionprovof the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. • By—if1r1 t tle71�"'��_ TYPe tcense: 1 S/ ' • t • lumber Title 103\72.t ' ❑ Glitter Sig - - fe of Licensed Plumber/Gas Fitter � �-_ _ l' p aster City/Town ❑Journeyman cense Number: A5 /�G//� n APPROVED(OFFICE USE ONLY) 0 LP Installer . .