HomeMy WebLinkAboutG-10-282 ""o �4 APPLICATION FOR PERMIT TO DO GASFITTING
y. 9
F3 ;g,' TOWN OFFYIKM UYF D (OFFICE USE ONLY)
By
`- :::, ;:�- •' OCT 2 3 2009 Fee: $ / /�� # 6
``�� �t//J PERMIT NO. Q. 6
11PDMG DEPT. � _ �
Date r �'�
Building ��Lig,
�� / / Owner's p
GAT: Location 6 V/ 1�V ^ Name PftiaIQfeT(1�J�R9 ��
Type of Occupancy �l -
New❑ Renovation ❑ Replacement Nv
Plans Submitted Yes❑ No❑
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SUB-BSMT.
BASEMENT 2-
1ST FLOOR
2ND FLOOR
3RD FLOOR
(PRINT OR TYPE) � �� � Q Check One:
Installing Co any Name �.n e Pt g 0 Corp.
Address � // Ct R. 0 Partnership
PW L1RCb✓� G` ' (,VSA 02%3 'Firm/Company
Business Telephone S°� 367— 3 / '
Name of Licensed Plumber or Gasfitter R L'2 'oi
INSURANCE COVERAGE: Check O e
I have a current liability insurance policy r its substantial equivalent. Yes No 0
If you have checked yes, please indicat the type of coverage by checking the appropriate box.
A liability insurance policy Other 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 Mass. General Laws, and that my signature on this permit application waives this requirement.
Check One:
Owner 0 Agent ❑
Signature of Owner or Owner's Agent
Wer—SC
I hereby certify that all of the details and information I have submitted Signature of Licensed
(or entered) in above application are true and accurate to the best of Plumber or Gasfitter
my knowledge and that all plumbing work and installations performed Z60 9'9'
under Permit issued for this application will be in compliance with all
pertinent provisions of the Massachusetts State Plumbing Code and License Number
Chapter 142 of the General Laws. / TYPE LICENSE:
LJd Plumber El Gasfitter 0 Master SZourneyman