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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type) �i/ ,/�
I• l Q Y ,Mass. Date 1 /—/9 20 /` Permit// C-12--0 3O
€�='C"=gI Building Location/7f- Jagez.... Owner's Name,//4i pAr
-14,.,,�°g" • Owner' / ' ` �'� Type of Occupancy PLO
Sa839jI / 7Z
New 0 Renovation ❑ Replacement Plan Submitted: Yes 0 N
FIXTURES
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0 g / it ° E EUILDIN3D=PT
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rmte 6 = 00i0 `110 8 ,4t N
SUB-BSMT
BASEMENT I
1•T FLOOR
2N0 FLOOR
Sep FLOOR
4TH FLOOR
5TH FLOOR
6TH FLOOR
7T"FLOOR
6T"FLOOR )
Installing Company Name.E feA�w7SIG!O A-/7 /.C: Checkckone: Certificate
Address el �f--�.�'7j /3,e e t o_26451 tt poratlon J,�S1 Com.
d, �/7LJLniii,��7414 ❑Partnership
Business Telephone# '�17 P �Y 91 ?/ 7 7Le �) 0 Firm/Co.
Name of Licensed Plumber or Gas Fitter . r//-Q/) J •/� )117Z,he.Z
INSURANCE CO RAGE:
I have a curre lability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142.
Yes No o •
If you have checked yes,please tate the type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity o Bond o
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. /
Cheer ')
• • of Age, •
Signature of Owner or Owner's Agent
I hereby certify that all of the details and Information I have submitted(or entered)in ab• • applicat' are true :n•as 'te to the be • , y
knowledge and that all plumbing work and Installations performed under the permit Issued fo q. - :iIication i •mpliance
reriinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General La
By Type of License:
••Plumber Signature of Licensed Plumber or Gas Fitter
Title •Gas fitter � eg
✓•Master License Number fJ.fb,1
City/Town •*Journeyman(OFFICE USE ONLY)