HomeMy WebLinkAboutG-11-747 ___ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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Building Location: �r+ p� R Owners Name:
GType of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional 0 Residential aien to ' H
New:0 Alteration:0 Renovation:0 Replacement: 0 Plans Submitted: Yes 0 No 0
FIXTURES
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SUB BSMT. 1111111.1111.111111.11111.11.11111.1.11011.11.11.11111.111111.11111.111.1.111.11.1.10
BASEMENT 11.111111101.1111111111111111111111111.111.11.1110.....1111111111111111111111111111111111.11101
1 FLOOR INIMIIIIIIINIMIIMINIMMOIMIINIIIINIMIIMINIIMI-MIIMINIII1111111.11111MINI
2 FLOOR 111111•®1111101111111•11111MIIIIIIIIMISINIMIMM11101011111IINIMIIIIIIIIIIIIIIMI
3 ' FLOOR 111111111.111111111111111111.11.11111.11.111.1111111.11111111111111111.111111.1.11111111.111.1
4 FLOOR 11111111111111.1111111.111111111.11.11111.011.11.1111111111111111111111111111111111111111111.111
65 FLOOR 1.1.11.11.11.1.11..1.111.11.1.111.11.1.11.111.111111.1.111111111111111111111.111111111111
FLOOR 101111111111111111111MMIIMIENIIMINIMIIMIIIIMIIIIM111111111111111111111111111111111111
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7 FLOOR 11111.11111.111111111.11111111111111111111111.11111111111111111111.1111111101111111111111111.1
S FLOOR 1.11.11....111111.11.11.11111.11111111.11.1....1.111.11.11.11.11.11.11.111.1.11.1
Installing Company Name:
Check One Only Certificate#
Address:C� q '• 0 Corporation
City/Town: �_ State:jL1' �—
Business Tel: SOQ-.? _'fly�( Fax: 0 Partnership
Name of Licensed Plumber/Gas Fitter: 451.-N1 • \ 0 Firm/Company
INSURANCE COVERAGE:
I have a current Iia iii 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 X 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 wits this requirement.
Check One Only
Sl.nature of Owner or owners 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 In tions
corn with all Pertinent provision of the Massachusetts State Plu • ngW •or the permit issued for this application will be in
■ ; ode I'[;,.illI of the General Laws.
By err �t!��k 5 of Plumber
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❑Plumber �, I/ L -
The I US 0 Gas Fitter Signature of Licensed Plum
-r 8 MasterGa;Fitter
City?own 1 • Q Zjjoumeyman �/
APPROVED OFFICE USE ONLY 0 LP Installer License Number: