HomeMy WebLinkAboutG-12-057 7- 3 - ' 1 jate-
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
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..+, I. -s.Et�( �/ I �I VAT--MO ly,Mass. Data—T29 20,_Permit u ./2 —oc 7
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a� Building LocationC (g T��1G^/ f V lLt c t t. r r7�ry Owner's Name ry(�
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cc,,,,-.01 • Owner Tell 045 &)V' I e of Occupancy WSI titer/
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ew ❑ . Renovation a Replacement�( Plan Submitted: Yes' ❑ NOS(
FIXTURES
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SUB•BSMT
BASEMENT
1"FLOOR X .
2'43 FLOOR
4 15D 3RD FLOOR
4Th FLOOR
5Th FLOOR
BTM FLOOR - _ ...
7Th FLOOR _. _. .... ._. _ .. ... . ..
fiTh FLOOR
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Installing Company Name E`e4' 75/0 J 73-JT (_t) Check one: Certificate
Address 07 'f f�weA'1 /kat B'Corporation %Sae&
N 4/4 o266/
��r �/7��%; h�7Y v _ o Partnership
Business Telephone# 57 P t ' �"?7 77e / ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter N 7%oh-e/) i '40/125))6(
INSURANCE COyERAGE:
I have a cure lability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142.
Yes No 0
If you have checked •Les,please irate the type coverage by checking the appropriate box.
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
Mass.General Laws;and that my signature on this permit application waives this requirement
Check o
ner Agent O
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered)in a ve splice n are u- , , accura . • e best of my
knowledge and that all plumbing work and Installations performed under the permit Issue this plicati' ; •e co • .nce wl •all •
erttnent provisions of the Massachusetts State Gas Code and Chapter 142 of the General La //
By Type of License:
••Plumber Signature of Licensed Plumber or Gas Fitter�
Title •Gas fitter .702>�]�yy
./Master License Number �F 2
City/Town ••Journeyman
APPROVED(OFFICE USE ONLY)