HomeMy WebLinkAboutG-11-204 .NAY: o`ZS PARCEL : 63 1
i� MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING •
(Print or Type) 7 n
e " 1• . \ ___ , Mass. Date ' 9"3G 2.0 /O Permit # Qi (—( (J if
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Building Location ', N1-IS-1 �IQQVi2LJ i� Owner's Name Fla D #LUS C'M�bn
/. BO• is LICu.Wtuu•tk Type of Occupancy IES iC.>!2K CLL
(village )
New ❑ . Renovation 0 Replacement Plans Submitted: Yes:
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C 'S C r7• S L 7 O C J U C ! O G M' •• ^
SUB—BSM?.
BASEMENT _ I { $ y�
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1ST FLOOR _ I I
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2Ti0 FLOOR 1 _
IN ORD FLOOR ,
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ATH FLOOR
•
STH FLOOR , £EPTED �j J�/�
• 67K FLOOR • BE �Ya((�,1.
7TH FLOOR . •. '
67H FLOOR- .. • '
Installing Company Name Rusty ' s Inc. Check one: Certificate
Address 222 Mid—Tech Drive Corporation '• 1762-C
West ' Yarmouth ❑, Partnership
Business Telephone 508-775—L303 C Firm/Co.
Name of Licensed Plumber or,Gas Fitter Frank W. Roderick • _ ,
INSURANCE COVERAGE:
• I have a curiej. liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No 0
If you have,checked/es. pierse Indicate the type coverage by checking the appropriate box.
A lability insurance policy Other type of indemnity 0 • Bond O
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass. Genera! Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner: Agent❑
Signature o1 Owner or Owner's Agent - -. . - - -
•I hereby certify that all of the details and information I have submitted (or entered)in above application are true and aaurate to the best of my .•
•knowledge and that all plumbing work and installations performed under the permit ie ued for this applicaUon will be in compliance with all
pertinent provisions of the.Wassachuse.tts State,Gas Code and Chapter 142 of the era)Laws. -
B T o1 Ucerse: I• "// � to' 1 ' . /nQ
•
^ - r umber . ,Sig nature of Utensef lumber or Gas Naar ...
Title �Gaserer
Master License Ncmter .7794
CityAP'ROYEb(OFFICE USE ONLY umeymzn