HomeMy WebLinkAboutG-11-834 •
•
•
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
C,.—sr City/Town: VAI21'h/1/JTN , MA. Date: 9
1•V Building Location: S c No Aannb Owners Name: h.evact/) Lie/viva)G Type of Occupancy: Commercial 0 Educational❑ Industrial 0 Institutional 0 Residential g
New: ❑ Alteration: ❑ Renovation:❑ Replacement:W Plans Submitted: Yes❑• No❑
FIXTURES
00
Lit- • re Ill a y tn
co _ RECEIVEDI
re 0
O I- QKX UJ IX
O QZ -t >. re Z to 0 O QWQ 7 JUN 0 0 2)11
- N > W Z C' m O ~Q lL F W 0 re 0 cr. W
IL W U W 2 t7 'U IU1 Ill W- Z be F- O to j LLI I-(9 LL N = Z W W ILI
K sr. BUIL�INC DEPT.
0 o o � 0 0 •:( Z 5 O C. g ri IW- g ? > R o
SUB BSMT. •
BASEMENT I '
1" FLOOR
2""FLOOR
3"u FLOOR —
4'"FLOOR
51"FLOOR .
6'"FLOOR
7'"FLOOR
8'" FLOOR •
Check One Only Certificate#
Installing Company Name: E/-7/y/VSLVe• •
p(Corporation
�/C
A /� /� /� �' i�p Corporation
Address:( 1�EE1gfrA l eZLECity/Town: L rfIRoner 7/ State: �iq. / `
Business Tel: S 395'7771 1'9 Fagg tet ❑Partnership
Fax:
0 Firm/Company _
Name of Licensed Plumber/Gas Fitter: ,.9 CP//E,I/ 44 i//,t/Sz( iti
INSURANCE COVERAGE:
1 have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 Yes 'No 0
If you have checked Yes,please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy pf 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"
Signature of Owner or Owner's Agent Owner ❑ Agent ❑ `
By checking this box 0;I hereby certify that all of the details and Information I ve submitted r en .red regardi• , this appii•. •n are true and
accurate to the best of my Knowledge and that all plumbing work and Installati s performed der the • rmi s ed for thi ... icatlon will be In
compliance with all Pertinent provision of the Massachusetts State Plumbing Co and C r 142 of t•_ i I Laws.
Type of License:
By
0 Plumber
Title Gas Fitter Signature of Licensed Plumber/Gas Fitter
Master
City/Town ❑Joumeyman License Number: /&a 9P
APPROVED(OFFICE USE ONLY) 0 LP Installer