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MASSAC USETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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tee--- + Clty/Town:�. VRr r.duTJl MA. Date:/3 BI LOI G
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Building Location:_/es-
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Owners Name: is Arz<p r
G Type of Occupancy: Commercial❑ Educational 0 Industrial
0 Institutional❑ Residential
New:,1 Alteration:0 Renovation:0 Replacement: 0 Plans Submitted: Yesa No❑
FIXTURES
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4 FLOOR 11111.11.11.11111.1.1111.1111.11111.1111111111.11.11.11111.11111111111.1111111.111111111.1
5 FLOOR INIMIIIIIIMINIMIIIIIIIIIIIIIMIIIIIIMIIIIIIMINIMINOINIIMIMIIIIIMIIIIIIIIIIIIIIIIMI
7 FLOOR 6 FLOOR 111110111.11111111.111.11.111111.11111111.11.111111111.111111.1111.11111111111111111111111111
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Insiailing Company NMI! .S i a # ' Check One Only Certificate#
Address: 19 S CltyfTown: `�f V19rhyJ11 17 State: Y✓J�i 0 Corporation
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Business Tel: cpF- 367-C)3�i Fax: ❑Partnership
Name of Licensed Plumber/Gas Fitter: /9..C(337 /0 v
0 FlrnyCompany
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 iv Other type of indemnity 0 Bond
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
Si s nature of Owner or Owner's A.ent Owner 0 Agent 0
By checking this box ■;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.
By i'la jl a ,.�� Type of License:
jil Plumber �J
Title N9 ❑Gas Fitter Si to of'L censmber/Gas Fitter
❑Master
CAPPROVE•rovm i`�a..-- ❑Journeyman
OFFICE USE ONLY 0 LP Installer LI use Number: %-37—307lid