HomeMy WebLinkAboutG-12-040 •
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
f• .,-dr-----1 Yylf{f,/7 ffT'(l ,Mass. Date/7 7l 10 /./ Permit#GI2 -O'T'/
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Building Location /7 72E1, Owner's Name ////e( ��C r
tb-k*.. • Owner Teti/ 5-0S 70 d-57 Type of Occupancy 5y/
New 0 Renovation 0 Replacement Plan Submitted: Yes ❑ No 0FIXTURES /
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ddiJflVflL ma co 0
. 0 U 85 > . 58o E
SUB-BSMT C ,
BASEMENT
1^FLOOR I j Cv[1 V.1; {G •M
2ND FLOOR
3RD FLOOR II JU_ w 2 2011
4T"FLOOR
5T"FLOOR RI LONG )EF T
6T"FLOOR ,.•B•
7T"FLOOR ,
8T"FLOOR )
Installing Company//o� Name
E /'U//7s/L)/() Ju 71 Checkckone: Certificate
Address 0 giFeg�OO (3€(sit / / ih poration 2261
CSi Y/�Lzfl;141/2 /f <? c;u/ CI Partnership
Business Telephone# �!P �'f Y- �'"?/ 77/3 ,/, 0 Firm/Co.
Name of Licensed Plumber or Gas Fitter v 71 ?fl/1_e/) g •1.A.117)51)1/_J
INSURANCE CO RAGE:
I have a erre lability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142.
Yes No o •
If you have checked X22,please tate the type coverage by checking the appropriate box.
A liability Insurance policy Other type of Indemnity o 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 o•-:
Owe •ge• •, '
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered)In --•ve applicati Ore tru: and a 'urate to - •;• of my
knowledge and that all plumbing work and installations performed under the permit Issued o , "A. natio be compile th all
ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Law
By Type of License:
•'Plumber ignature of L tensed Plumber or Gas Fitter
Title •'Gas fitter � �
✓•fvlaster License Number
City/Town •'Journeyman
APPROVED(OFFICE USE ONLY)