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HomeMy WebLinkAboutG-11-456 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING scram ` t !trill' City/Town: /.9/Y{2p 04 , MA. Date: p/-0 3-'// Permita I ieliS/ Building Location:tea .r// a , At Owners Name: Orrin PVA / /Ca r1 GType of Occupancy: Commercial 0 Educational 0 Industrial ❑ Institutional 0 Residential ©- New: m— Alteration: 0 Renovation: 0 Replacement: 0 Plans Submitted: Yes 0 No EL- FIXTURES -FIXTURES CO CI) CO Z ~ U _ co pTC � d � g ¢Q cc z O F D CO = 0 W W O to H O = K W 0 w g Z m o ai ¢W p ~ Imo- AN 0 4 RECD > V w z O -I FEW- H O ? -W-1 0 vj O 12 = isiZ V-1 w w g y / U 0 0 LL fag 0 r S J O d R' K IW- E ? > 3 O SUB BSMT. BASEMENT . 1s FLOOR t 2N°FLOOR 3"1/FLOOR 41" FLOOR (' 6'" FLOOR Vttti 6"4 FLOOR +2'A: 7'"FLOOR 8'"FLOOR Check One Only Certificate# Installing Company Name: mLO(CuX /bm/)ag J 0 Corporation Address: City/Town:Q$4fl11 A0 State:k 0 Partnership Business Tel: 372-)420_..p 69 Fax: �dR-O'1-`7 '9-? /Company Name of Licensed Plumber/Gas Fitter:NY e� ha inn Ore n K INSURANCE COVERAGE: /� `P� I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 Yes III-No 0 If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity ❑ 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 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. B Type of License: Y [L}Prumber Tile 0 Gas Fitter S'. :ture of Lice 4"Ird Plumber/Gas Fitter ill-Master City/Town ©dourneyman License Number: A5737 5 APPROVED(OFFICE USE ONLY) 0 LP Installer