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HomeMy WebLinkAboutG-11-663 • -.. MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type)/[/� �7 l • IP_.erWa,4 ..r. , � �Q�/�(,��Y// ,Mass. Date ©e -// 20 1/ Permit# a`I — GO-5 Building Location /S NO - LAI Owner's Name(.�(t!fl C y oii,k Owner Tel# 510 .-3913 r3 -9 6p17 /Type of Occupancy 7,S / New a Renovation 0 Replacement cr Plan Submitted: Yes a No IY FIXTURES G ,Aort,s, 1+7 / k z F s a �w ,� s M ')`� o O _ 2 6 3 c u 3 ° $ a $ o E 1-f 7—• SUB-BSMT � BASEMENT , �l7AR 1 in FLOOR 2N°FLOOR Ei ILL NG pFt r 3fle FLOOR 4TM FLOOR STM FLOOR _ BTM FLOOR 7TM FLOOR — 8r"FLOOR r ) /� Installing Company/ Name EF(�//7sJ0/O p31 /2? Checkckone: Certificate /� Address e> �Er4,ecA2 4e e/t / / ti:Corporation 32S/ C. c-5, iktizmnA1/2�7,414� C966/ ❑Partnership Business Telephone# 57}13 z. Y T -7 7 /�7L6 /� 0 Firm/Co. Name of Licensed Plumber or Gas Fitter ,oh-e/) !f •/22/ ns z) INSURANCE COVERAGE: I have a curreen/liabiliy insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. Yes No ❑ If you have checked in,please irate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity ❑ Bond 0 OWNER'S INSURANCE WAIVER:1 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 gee Owner e" Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and Information I have submitted(or entered)in ab e applicatio are tr d a urate to the ist of my knowledge and that all plumbing work and Installations performed under the permit Issue this 'cation w' .e complian ith all ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General La � " By Type of License: /l-•✓ ••Plumber • Signature of Licensed Plumb• or Gas Fitter Title •Gaser 744.2-it �hAaster License Number City/Town ••Journeyman APPROVED(OFFICE USE ONLY)