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Home My WebLink AboutG-12-029 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) y /�, are .ee p al•(/(//(�A�r1 O riffass. Date ' / • IS 20 ripenmit t — —.027 ..=_1= Building LoYation / n 0 N .5 V e-il caner' Name TA MCP' w �1 N 9 �•0 • Owner Tell# 7 g / 2T •soy-7 Type of Occupancy New 0 Renovation 0 Replacement Plan Submitted: Yes 0 No 0 Fl URES GrIn LG SUE III1 0 ©� r Ill JU'. 782011 Li 4000. 6 b cel� N t7 0 i z g w g 0 2 LCULGJEPT W) ` �a i I s El - a v col g > § F n "— SUB -BSMT soy BASEMENT ' 1"FLOOR _ , • 2'41 FLOOR , , 3"e FLOOR , , 4T"FLOOR , 5T"FLOOR 6T"FLOOR 7114 FLOOR , 6T"FLOOR / /� Installing Company NameEfrifei7s,/O/O rte/ (_C; Check one: Certificate Address P> �r�},e,/e4 (it Cry'(_._ la— oration .f�,� /S/ C L °5; j/e p�i ' 'Ma7 0266/ 0 Partnership Business Telephone# ' IJP 3 Q Y' — / 7 78 ��)� ❑Firm/Co. Name of Licensed Plumber or Gas Fitter '� /.Vr/5-Q/) i2 • /1'jSA1(,0 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 yes,please ieate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity 0 Bond 0 OWNER'S INSURANCE WAIVER:I em 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•-: -er '- Agen ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted(or entered)In a•- e applica • are true , d a• urate • •est of my knowledge and that all plumbing work and installations performed under the permit Issued • this, plication I •• com• •-with all lertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General ,a'. By Type of License: •-Plumber Signa ire of L ensed Plumber or Gas Fitter Title •Cas fitter %,�J /I /J •✓Master License Number /1�-.f-% City/Town •'Journeyman APPROVED(OFFICE USE ONLY) f 1.