HomeMy WebLinkAboutG-11-263 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or �Tny�p/e)Q���� II
IC " • of iMIA 't , Mass. Date I0-'d 20 J
s T..',I• I_' v City, Town Permit 16) 2(p.3
Owner ' s ' I
.,1 '_' AT : Location 16 6t f11u0IL'CV4� Name �N 14
__ . !4!1MVY`lR TYPe of Occupancy: _ �---- .
New Renovation ❑ Replacement ❑ ,
Plans Submitted Yes 0 No 0
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a • 'Sup.—SSMT. _ _
t' BASEMENT
_ . 1ST FLOGS • _ I
n 2ND FLOOR
SRO FLOOR _ _
o •• 4TH FLOOR a co
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6TH FLOOR - c'.
-w; 8TH FLOOR ,_
7TH FLOOR
^8TH FLOOR
(Print or Type) .
losq
�� �I/ A c'Iti� Check One: Certificate
Installing Company
��Name
� //��y�(� b WUU �I�� ,
Address 4i LDWt]L Q ti Rao 0 Corp.
Partnership
-- WK#M1 NIA. 11k— _ ❑Firm/Company
Business Telephone � -'02.— Name of Licensed Plumber or Gasfitter
•
l hereby certify that all of the details and information(have submitted(or entered)in the above application are true and aaunte to the bat of my
knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent
provisions of the Massachusetts State Oat Code and Chapter 142 of the General Laws.
l have informed the owner or his agent that 1 do not have liability insurance including completed operations coverage
Signawre of ewnaor agatt
(haveacurrentliabilityinsurancepolicytoincltdecompletedoperationscovaaga0 r �• _.arille
TYPE LICENSE: Si• -tureof -rnsi{e
By Title C Plumber PlumberorGss a
0 Gasfitta
CityfTown - 0 Journeyman I
.Approved(office use only) )(Mata • • ?L.I5(lo`2.,