HomeMy WebLinkAboutG-11-047 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
C _•"I-_� City/Town: A • 1 g a , MA. Date: Permit#(1 I .. 047
�v,y- L,�/ ��'' 0 UR/t'�/
sit
Building Location: / sCa' / S, ,_ Owners Name:/2 of �" `�' `h " '
G Type of Occupancy: Commercia 0 Educational 0 Industrial 0 Institutional 0 Residential 133---
New: 0 Alteration: ❑ Renovation: 0 Replacement:V Plans Submitted: Yes❑ Nom/
FIXTURES
co Io
er0
tUJ Y ix
W Y CC
0
N re
2 rl- co iii
m = 0 fW9 J U (D H N L W LU
LY
�0�3 ZI_ a W Z � � oa �
Nw co w m Q O W - w X
El
F- ce ¢ w w w Z 5a rn =UJ w wtIC z w Is'0 RCC[PT[D e, n
U W Z to J F- P 0 Z J 0 W p = W i- W W ✓C
ty) 0 o'EA0 u... 0 0 = z g 0 0. gc K H m >ZI > p.I. o
SUB BSMT.
BASEMENT J I
FLOORCi
ZEEIVE D
2N'FLOOR
3"OFLOOR - 2 3 n10
4'"FLOOR
5'"FLOOR
6'" FLOORBT.
UI.JIN3 DEB
7'" FLOOR ly
8'" FLOOR
Check One Only Certificate ft
Installing Company Name: E. F, P✓/NSLDW/ INCrit Corporation /6a5---
Address:2 / A,€A V d/, th City/Town: g. 7RRnoo State: MA
9p?V/ ❑Partnership
Business Tel: S08"3 -2 7.7.e Fax: 508-3qV-• Pas,
❑Firm/Company
Name of Licensed Plumber/Gas Fitter: E. F INiIV5LOu) :Iii:
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes p No 0
If you have checked Yes,please Indicate 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: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 waives this requirement.
Check One Only
Owner 0 Agent 0
Signature of Owner or Owner's Agent
By checking this box❑;I hereby certify that all of the details and information I hay- •m'•.d(or entered)regardin• his application are true and
accurate to the best of my Knowledge and that all plumbing work and Installatio - perfo,1-• nde he permit iss -• or this application will be in
compliance with all Pertinent provision of the Massachusetts State Plumbing C•de an •.p - 14. • the Gene . :ws.
Type of License: 4 1t
By 0 Plumber
Title ❑Gas Fitter Signature of Licensed Plumber/Gas Fitter
0 Master
City/Town _ ❑Joumeyman License Number: 793 9
APPROVED(OFFICE USE ONLY) 0 LP Installer