HomeMy WebLinkAboutG-12-295 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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Z �rcr' P MA Date: tile-I( Permit#{ ♦y2- ' A�5�-F• City/Town: en✓ dr A. ''Building Lo tion: A/.53 M ,� S „ 74/L-Owners Name• ,�6..< Wp^ y
GType of Occupancy: Commercial 0 Educational 0 Industrial 0 I titutional 0 Residential 0
New: 0 Alteration:0 Renovation: 0 Replacement: Plans Submitted: Yes 0 No qJ-----
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^� 71 FIXTURES
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SUB BSMT.
BASEMENT
1a' FLOOR 2
2"FLOOR
3"FLOOR
4'"FLOOR
5'"FLOOR
61"FLOOR -
7'"FLOOR
81"FLOOR '''' ��
Installing Company Name:. o7'1.4_ Check One Only Certificate#
/// n4_ 0 Corporation
Address:/D2'7tra CitylTown: 44Psi as ,Uf(�State: M
0 Partnership
Business Tel: ,4o1 - '- e53 0 Fax:
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Name of Licensed Plumber/Gas Fitter: (SDy Q l�, i`
INSURANCE COVERAGE: 1
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 Yes
If you have checked ,please indicate pe of coverage by checking the appropriate box below. II/��
A liability Insurance policyOther 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 0 Agent 0
By checking this box❑;1 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 hapte • the General Laws.
B Ty of License: r ►� / /
By
Plumber 1tilli v
Title Fitter Signature License • tuber/Gasutter
Master
City/TownJourneyman Ivens umber: /0‘7 T
APPROVED(OFFICE USE ONLY) 0 LP Installer