HomeMy WebLinkAboutG-12-323 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
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= l Y4-senohi? ,Mass. Date 1/— ZZ 20 // Pernnt#r i2— 323 (�
.Building Location
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!8 gkil 14e 4 Tel___Owner's Name (/ V
%.�. • Owner,Tel# 7 r 0— 72/. S�? Type of Occupancy RO
New 0 Renovation ❑ ;Replacement - .. Plan Submitted: Yes 0 No
FIX1URES
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BASEMENT
in FLOOR
• 2"a FLOOR
3"a FLOOR
4T"FLOOR
5tH FLOOR
STM FLOOR
7tH FLOOR
BT"FLOOR •� ) /� . . _..
EcrL'61/5/vl ) y�3-ti /.(i Check one:. Certificate
Installing CompanynName / ,oy� /;
Address 0 7 4Et? ,)2 4_16/e-- orporation S LL
G Yea AI* MA 02661 a Partnership
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c-5, ���-c-1r- ���i n�/ 7
Business Telephone# 17..)R =Y 9 7 7e //�� ✓ot cFIr{mn/,C/o.
Name of Licensed Plumber or Gas Fitter Spite ih-e/) i ✓ •���/`-'/"V`.)
INSURANCE cO ERAGE:
I have a arra lability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142.
Yes No a
If you have checked Lel please irate the type coverage by checking the appropriate box.
A liability Insurance policy Other type of Indemnity O Bond a
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. o -.
• ner Agen •
-
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered)in a t• e applica ie are true d accurate to I • I of my
knowledge and that ell plumbing work and Installations performed under the permit Issued • 4.46,-..•Iicatlon 0 be •m•Iia , th all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General La -
Type of License:
By •-Plumber Signature of Licensed Plumber or Gas Fitter
Title ••Gas fitter `1' 211)
.Gaster license Number
City/Town •-Journeyman
APPROVED(OFFICE USE ONLY)