HomeMy WebLinkAboutG-12-168 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)__""��1�� /� /
Gn (d 14/ )4rviio rk ,Mass. Date 9/74 20 1/ Permit 2-- -- 16
J I_ �,l �
=' 1 Building Location 5)- hnI .5-/. Owner's Name £Wn/f /v s174lgt/4 .
%..-,.,. Owner Tel# 5D9----301--24 36 C41" Type of Occupancykil l'
J
New fl Renovation 0 Replacement 3< Plan Submitted: Yes 0 No
FIXTURES
G
� � , „ L1,
......
45Ut� N o � i ti 0 .0 S=P 2 ' 201
z -.0- v.: ogwrz nw z00 ° x �' ` G BUILDINGDLP1
i.(so d i o u ; a a Q ' u a . Q rn° t-- 0 h. .
SUB-BSMT
BASEMENT
1°T FLOOR
(, 2ND FLOOR
3RD FLOOR
4T11 FLOOR
_. STN FLOOR • -
.t .. - . 6Th FLOOR .-... .
7Th FLOOR ,
8Th FLOOR _ ..
installing Company Name'.)'1" gory 15 7-n1G . Check one: Certifibate
Address P7.2 Mld—Tedi 0n;/e. Corporation 17Gz C 1
'Afar yamt ma, MA 02473 o Partnership
Business Telephone# 508-775— 1303 ❑Firm/Co.
Name of Licensed Plumber or Gas Fitter FRANK W. Ieodennd<
INSURANCE COVERAGE: •
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142.
Yes No ❑
If you have ctecked yes,please Indicate the type coverage by checking the appropriate box.
A liability Insurance policy S •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
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 ;; .4,:,. .t! 1 ., , .:•....4... .:... .. -_ __.:
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
knowledge and that all plumbing work and installations performed under the permit Issued for this application will bein compliance with all t'" "S
ertinent provisions of the Massathusetts State Gas Code and Chapter 142 of the General Law�s.-''" I, r e L. ' i. . ' r rr. I I
BY r r - S Type of License r • t" . fp. VV _
_1 r :•-•Plumber ; r i 2 I Signature of Licensed Plumber or Gas Fitter ;
"
�' Title7. t 1 :• Mastfitter r)' ! ( ! I ' 779 I ..,'. j �
OFMaster.)' f License Number
- City/Town • ` r
APPROVED(OFFICE USE ONLY)