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HomeMy WebLinkAboutG-11-786 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) Gn /^ --_�_f �f��/yf��/�� ,Mass. Date©5—•£9 20 // Permit ;GI I^ cv �/] —g� Building Location %0 ,244,11,jrztsi 41._ Owner's Name 0 b�+1.• ownerTef/ JtOb 3(v Z' -i 1 Type of Occupancy New 0 Renovation 0 Replacement Plan Submitted: Yes 0 No ' FIXTURES . GRECEI '!7Y E gEjtAa\Yi90h1 Z z (� m M q L4 tel 9 d m FUILUINa I)_PT - - g i il 0 0 _ . 3I. c o u , cl W R SUB-BSMT BASEMENT 1sr FLOOR 2'a FLOOR 31D FLOOR 4TH FLOOR 5"FLOOR 6TH FLOOR _ ... _ 7"FLOOR 8Th FLOOR ) Installing Company Name Eftiei7 kit) /-H ii) Check one: Certificate Address F> ii2E17tG1-/2 /IE( t ' oration �RjS / c5; *ziiA,./ 02641 0 Partnership Business Telephone# 511e C5V 91 —7 - / J /�/1 / 0 Firm/C/o. Name of Licensed Plumber or Gas Fitter Sf-eet) -•?/) ,' •t Dios,h l) INSURANCE COyERAGE: I have a rune liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. Yes No 0 If you have checked yes,please irate the type 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. caner ..A O Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted(or entered)In above a••' 4/ are tr e n curate:crate t.4-: best of my knowledge and that all plumbing work and installations performed under the permit Issued for th- •plicatio 'I•,.In comp) • Rh all ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General La - By Type of License: •'Plumber gnature of Licensed Plumber or Gas Fitter Title •Gas fifer 44,21g) ',Waster License Number Citylrown • Journeyman APPROVED(OFFICE USE ONLY) - -