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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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' amla . City/Town: `Lc mcult innf-1" ,MA. Date' 9.76 bo r f Permitter)2 - ) I 4,3
Building Location: /93 Sehtncte/- Cj> Owners Name: R c hard (fee-Ad/Ca U
G .
Type of Occupancy: Commercial 0 Educational 0 industrial 0 Institutional 0 Residential Eli
New:0 Alteration:0 Renovation:0 Replacement:E/ Plans Submitted: Yes 0 No 0
e I FIXTURES
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SUB BSMT.
BASEMENT ✓
14' FLOOR
2"° FLOOR
3N" FLOOR
4'"FLOOR
6'"FLOOR
6'"FLOOR _
71"FLOOR
8'"FLOOR /�
Installing Company Name:Rei R(F5 IEFR(GERF TLO N 1 TNS Check One Only Certificate#
P ®Corporation isci
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Address'a71 'wt auTH Ai City/Town: 141)-AINIS State: ffIFI
osto0I ❑Partnership .. . .
Business Tel: SDS-715-3083 Fax: SOS-'110 -D439 ❑Firm/Company
Name of Licensed Plumber/Gas Fitter.
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INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 Yes[I}No❑
If you have checked nig,please In cats the type of coverage by checking the appropriate box below.
A liability Insurance policy Other type of Indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER:lam 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
Owner 0 Agent 0
Signature of Owner or Owner's Agent
By checking this box 0;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. -
Type of License: I -
By ' 0 Plumber ir-_fir _ a..� - ia ....!-.....as /
'nue CI
Gas Fitter Signature of L tensed Plumber/Gas Fitte
❑Hueter 7 5''.3'
❑Joume
n License Number
APPROVED(OFFICE USE ONLY) 0 LP Installer
FINAL INSPECTION BELOW FOR OFFICE USE ONLY PROGRESS INSPECTION(Sl
FEE: $ PERMIT#
- - _ APPLICATION FOR PERMIT TO DO GAS FITTING
. _
NiiME&TYPE OF BUILDING
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LOCATION OF BUILDING
$NETT$
PLUMBER.GASBII IER.LP INSTALLER
• LICENSE NUMBER: - - - -
. _ PERMIT GRANTED❑ PATE.
i
GAS FITTING INSPECTIOR -.