HomeMy WebLinkAboutG-12-016 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or ITy'pe)
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+=q /] I Owner's Name // I/
" .la • Owner Tell) 90Y —hZ3/' ZZ Type of Occupancy X 5
New ElRenovation 1:1Replacement iY/ Plan Submitted: Yes ❑ No r
FIXTURES
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SUB-BSMT
BASEMENT I
in FLOORV
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2Ne FLOOR
3"o FLOOR , JUL 2 I Ll 1U
4T"FLOOR
ST"FLOOR
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6T"FLOOR ,
7T"FLOOR -
8T"FLOOR r
Installing Company Name
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Address 0 7'�9� (E(t/t / / f'Corporation Sae& C.L.
car/ Venn i/A% 'Ma7 o264/ ❑ Partnership
Business Telephone# 'fit ill z3 91 / 7 7e ❑Firm /Co.
Name of Licensed Plumber or Gas Fitter \S?7 ?rh-~Q/) g -10b9s v,c)
INSURANCE COyERAGE:
I have a curre lability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142.
Yes No ❑ •
If you have checked yes,please icate the type coverage by checking the appropriate box.
A liability Insurance policy Other type of Indemnity ❑ Bond ❑
OWNERS 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
Owner .sent ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered)in •'ova applicaay .re true and , uraty o the bes
knowledge and that all plumbing work and Installations performed under the permit issu:• • thi. _;C ication will •- /co •lance wit
eminent provisions of the Massachusetts State Gas Code end Chapter 142 of the General La, ;
By Type of license: ...
•'Plumber Jgnalure of Ucensed Plumber or Gas Fitter
Title •Gas fitter /� q /��
- Master - License Number ..2
City/rown •Journeyman
APPROVED(OFFICE USE ONLY)