HomeMy WebLinkAboutG-11-528 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
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(Print�oorr�Type) TLy -7 , C
I. b# c V r y'keMat.l �1 ,Mass. Date at' 20 (1 Permit N G cc -Sze
11= 9 Building Location 0- f LUAJF ••l 'J'Vr Owner's Name C.S
-444;. Owner Tell ' 9S:Tato• Ole-I • Type of Occupancy
New 0 Renovation 0 Replacement Plan Submitted: Yes 0 No"(
FIXTURES
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03 w
JAI l : R' CI J
K 2 O (0A mw - 6 E 3 0 U U w C 4 F-
SUB-BSMT
BASEMENT X
1°T FLOOR
21D FLOOR
3°°FLOOR
4Th FLOOR
5Th FLOOR
6Th FLOOR
, 7Th FLOOR
, 6Th FLOOR / m
Installing Company Name.tertaIfS/L)1O Pill (.t Check one: Certificate
Address GG� �f'4 7/2 c �f/�. / / tr'Corporation S,eS`
�1r *it'�p%i 1�4 7' / et oS6/ 0 Partnership
Business Telephone# 2,7 ) z 4/ ¶1�-?/ 7 7 f 7 a Firm/Co.
Name of Licensed Plumber or Gas Fitter v ph-Q7) 72 -buil-As yi
INSURANCE CO RAGE:
I have a curre lability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. 9
Yes "° ACCEPTED e v___,,,
If you have checked yes,please irate the type coverage by checking Me appropdate box.
A liability Insurance policy Other type of indemnity D Bond D BY:
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.
•
•, ner '- •gent 0
Signature of Owner or Owner's Agent
I hereby certify that all of the details and Information I have submitted(or entered)in above ••Iicdrd are tru z an. a• , . to the best•
knowledge and that all plumbing work and Installations performed under the permit issued fort s ..pll =tion will •eit 'pH:- e wit. .I •
ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General . . r
By Type of License:
•'Plumber Signature of Licensed Plumber or Gas Fitter
Title •Gas fitter 7e�..� oP
•Master Ucense Number �J
City/Town •�loumeyman
APPROVED(OFFICE USE ONLY)