HomeMy WebLinkAboutG-12-246 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
"Viti` " 4. City/Town: /�R»1dUT!1 ,MA. Date: /0frVJl Permit#:Z 2
Building Location: /g RM. OA Owners Name: CAVA' l/✓�•t&it/
G Type of Occupancy: Commercial❑ Educational❑ Industtial Institutional❑ Residential 1212
New: ❑ Alteration:0 Renovation: ❑ Replacement: Plans Submitted: Yes 0 No 0
FIXTURES
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SUB BSMT.
BASEMENT /
1'r FLOOR
2"°FLOOR
3"°FLOOR
4'"FLOOR
5'"FLOOR
6'"FLOOR
7'"FLOOR
8'"FLOOR
Check One Only Certificate#
Installing Company Name: nLn / D LAt4mvnJ J
/
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Address:Vie owWA7 City/Town: 110 .)4iw � sate:011A
❑Partnership
Business Tel: ..5":0J-691-- 7Sd / Fax:,rDeP-3 9y:`c7 -I
❑Flrm/Company
Name of Licensed Plumber/Gas Fitter. AL 214.61.44-4,
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 Yes 0 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 ❑ 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
.. Owner 0 Agent ❑
Signature of Owner or Owner's Agent
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 installations performed under the permit Issued for this application will be in
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
n Type of License: ���' w
By 0 Plumber
Title
0 Gas Fitter Signature of Licensed Plumber/Ga Fitter
0 Master /
City/Town ❑.toumeyman License Number. — )1 3D7b
APPROVED(OFFICE USE ONLY) 0 LP Installer