HomeMy WebLinkAboutG-12-368 t MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
c.a"�= ' City/Town: \ r/1ygt 1) / 3/ Permit#tr'lZ-are
M11I=a` �n/?, MA. Date: II
Building Location: I b I /1/1 I nsr" Owners Name: 00/Y1c�
GType of Occupancy: Commercial VEducational 0 Industrial 0 Institutional 0 Residential 0
New:0 Alteration:0 Renovation: ❑ Replacement: Plans Submitted: Yes 0 No 0
FIXTURES
en
Ir' reco CC
vi
hW-
W
N U S
K W , n
CO S 0F W W V y O = C W D [ 1'i U ,
re > rn IQ CO a U 0 z rn a Q ill a 4 w O W LL '� DEC 1 2[11
W I- re Q W QW aaZ . = W I— =
O Le re z Q RR W W OO j 0 0 0 N ~ > Z FW- w ,.U.�;J7'��T
O O W Z z W Q O C i t��-t
SUB BSMT. O o o 'L a o s x 5 O R z f- > > > 0 /p Ic•: 12 !r C"
BASEMENT
1a' FLOOR
2NO FLOOR
3No FLOOR
4'"FLOOR
5'"FLOOR
6'"FLOOR
7'"FLOOR
8m FLOOR
j
Installing Company Name2 ,_ Check One Only Certificate#
p in/ ty Corporation
Address* � ) `S
d tee / CI /Town. Jnr State
/3 7 7 Llam^ 27 2- L ❑Partnership
Business Tel: v
❑Firm/Company
Name of Licensed Plumber/Gas Fitter:
INSURANCE COVERAGE:
I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142 Yes No❑
if you have checked Yes,please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy 0 Other type of indemnity 0 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 0
By checking this box 0;I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and
accurate to the best of my Knowledge and that all plumbing work and I tallations performed under the permit Issued for this application will be In
compliance with all Pertinent provision of the Massachusetts State P bing Code Chapter 142 of the General
Type of License:
By ❑Plumber
Title 0 Gas Fitter ature of Uyensed Plumber/Gas Fitter
0 Master
['Journeyman
City/Town License Number: �5d i
APPROVED(OFFICE USE ONLY) 0 LP Installer