HomeMy WebLinkAboutG-11-652 4. •
±Z. MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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_ City/Town:5 YQ//ij/f6 6? $/ ,MA. Date: 'sj /// Permit#G I —6 fa
Building Location: '�Q f ryi° e J Owner Name:g ,(/"
GType of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional 0 Residential(/7
— New:0 Alteration:0 Renovation:IIReplacement:0 Plans Submitted: Yes 0 No 0
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FIXTURES
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1" FLOOR
2""FLOOR
3""FLOOR
4'"FLOOR
S'"FLOOR
8'"FLOOR
7'"FLOOR
8'"FLOOR
Installing/Company N me: /%I/V/, PY Check One Only Certificate#
Address/p 50W e'ketity/Town: ✓, 5,/�,. / State: P 0 Corporation
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Business Telca c9 12-3 Fax: --e��%z/�
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Name of Licensed Plumber/Gas Fitter. , /?-1� ,,9 4//
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 Yes 0 No❑
If you have checked as,please indicate the type of coverage 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 haw the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waivethis
! requirement.
Check One Only
Signature of Owner or Owner's Agent Owner 0 Agent 0
By checking this box LII hereby certify that as of the details and Information I have submitted(or Mend)regarding this application are true and
accurate to the beet of my Knowledge and that all .lumbing work and Installations performed u A the permit issued for this application will be In
compliance with all Pertinent provision of the M • units State Plumbing Code and Cha•jr 2 of the General Laws.
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BY �IpL�Itt�l /• of Lio nee:
1 - Plumber aj .4/,
Title !. b G Fitter Sign " re o Lee -ed Plumber/Ga. e
Ear ster
AP Rown a..' .. . ' umeyman /�7/SY7
APPROVE. (OFFICE USE ONLY) LP Installer License Number �c.Y/ (O