HomeMy WebLinkAboutG-12-072 . , GS?'
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- MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
`I--"_ City/Town: �,� , MA. Date: 8,— �8— ` PermR#G 2-67 2__
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Building Location: I1.CM Pd Owners Name: IDWirt ci --,,,m i
- Type of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional 0 Residential ka/
IL__Ir New: 0 Alteration: 0 Renovation: 0 Replacement: 0.--e"Plans Submitted: Yes 0 No W
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SUB BSMT. .
BASEMENT I r • . •
1" FLOOR . .
' 2N" FLOOR- '
3kU FLOOR • J
4'" FLOOR
51" FLOOR •
• 6'" FLOOR
7'" FLOOR • '
89" FLOOR • . 1 .. •
�b" ��( .CheckOne Only Certificate
Installing Company Name• -fpy(i, Cat
Corporation C
Address: e " 1 ',1� tes Pt, City/Town: Y� State:�f) i
11111 Da.� 0 Partnership
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Business Tel: -3gg.)gO1 Fax: '17C'V_P&9 Y 0 Firm/Company
Name of Licensed Plumber/Gas Fitter: Z d Pf r ION.EfCsm- .
•INSURANCE COVERAGE: -
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes No❑
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If you have checked YJ 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 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 Owner's Agent \ '
By checking this box❑;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
corn.fiance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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�� 'raMW Type (cense: //
BB C-- .., v lumber a"
Title t 1..)e'p?c_ c.Q_ ❑„ Fitter Sign- - re of Licensed Plumber/Gas Fitter
11 aster
City/T,own l O ❑Journeyman cense Number: /570/ •
APPROVED(OFFICE USE ONLY) 0 LP Installer f/ - •