HomeMy WebLinkAboutG-11-608 a - "
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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".�;`."_ 2 City/Town: YALM0.0.1, , MA. Date: Ff Z 3 Zo -fo4�C
if Permit#C (
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Building Location: 51 I 2. fAre 241-4J Owners Name: fete.-' c#414?AP."
GType of Occupancy: Commercial 0 Educational❑ Industrial ❑ Institutional 0 Residential Er
New:0 Alteration:0 Renovation: 0 Replacement: [r Plans Submitted: Yes 0 No 0
FIXTURES
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- SUB BSMT.
BASEMENT
1" FLOOR -
2""FLOOR
3""FLOOR
4'"FLOOR
5'"FLOOR
6"1 FLOOR
7"1 FLOOR -
8'"FLOOR
Check One Only Certificate#
Installing Company Name: 41"II S-e^Jl r4-Uow,/,rray
/ ❑Corporation
Address:-21 r frtuaria,ros 14 40 CitylTown: 11424V/C4 State: int
0 Partnership
Business Tel: Cut Vs o Y3e2_ Fax: 50£ y)o yzf'3
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rirm/Company
Name of Licensed Plumber/Gas Fitter: ea/tea n.., Ate-rr2, 4
INSURANCE COVERAGE:
I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 Yes[ No 0
If you have checked Yes.please Indicate the type of coverage by checking the appropriate box below.
A liability insurance policy Er Other type of indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER:lam 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 Owners 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
co..• •nee with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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';► , ! 11 Type of License: •
B11", kits .. ❑Plumber
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les Fitter
Title yl� pgcl(yC Signature o Licensed Plumber/Gas Fitter
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City/Town aril ynav meyman License Number: / 2 a /
APPROVED(OFFICE USE NLY) 0 LP Installer