HomeMy WebLinkAboutG-12-074 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
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.l VVPn9 Y4HM0� ,Mass. Date 8/9 20 ft Permit# �—d 71
C7 IBuilding / 0./ %orris IC A-C-ii•
Location � �7/ �t� At- Owner's Name
—• Owner Tel (
mfr/ no — S�2 ( Type of Occupancy : �l et
New 0 Renovation 0 Replacement Plan Submitted: Yes 0 Noi
FI TURES
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= o _ 3 0 0 a u g > al c°. o w
kn SUB-BSMT _ ,
BASEMENT I
1ST FLOOR
2N0 FLOOR
3R0 FLOOR
S 4T"FLOOR
! r- _ . -STM FLOOR t: :-;.,. - ._
t
. . BTM FLOOR o _
Installing Company Name FNSTy�'S SIG Check one: Certificate
Address An Mld—Tech On'V Corporation 1762 C
War yovn M11 MA 02673 0 Partnership
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Business Telephone# SD$-775— /3 03 0 Firm/Co.
Name of Licensed Plumber or Gas Fitter FM-a w'. 12odenxx
INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142.
Yes No D
If you have lecked Yes,please Indicate the type coverage by checking the appropriate box.
A liability Insurance policy Si Other type of indemnity i7 Bond ❑
OWNER'S INSURANCE WAIVER:I am aviare 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 one:- ..
" ' • Owner 0 Agent 0
Signature of Owner or Owner's Agent ; . _1 i - ,
I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my 1--
knowledge and that all plumbing v{ork and Installations performed under the permit Issued for this application willbe_in compliance with all i. 1,___i
ertinent provisions of the Massachusetts States-Gas-Code and Chapter 142 of the General Laws 1 t { ' 1 i ? j i
By 1 ,•Plumber!+ I.
Signature of Licensed Plumber or '
! T eof License Nle t/✓.`. [S
Gas Fitter -� � --
Title - i •G-s fitter : I ' ( .779 !,t i I ' i
_
; License Number . - - •
CIty/Town . : '_ . . •rrneyman - ' ,. . _... • ,. ..,.. '
APPROVED(OFFICE USE ONLY) -