HomeMy WebLinkAboutG-11-353 /-/antOwne>- .5--o2-29y-3y5'y
1Zi. MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
•
�-sr— Clty/ToWn: � 6/'mduF
=;11_, MA. Dat.: / io ((--g_15.2_
' // ' Permits
Building Location: 3 / Site re"g t t/4
• Owners Name: �/C_ ,)"C �a �
G Type of Occupancy: Commercial 0 Educational 0 Industrial❑ institutional 0 Residential]—
stNew:0 Alteration:0 Renovation:0 Replacement:0---Plans Submitted: Yes❑ No
a
FIXTURES
� 7 o
N
N
,, O j
I
ifIll 11111 11 111
.SUB BSMT.
BASEMENT �in����� i ���inia������ tEM �MEMI
I FLOOR vl��a�al�al����alMi��al�� ea �n
FLOOR InEN111.1.11.1111.0.01.1.1inininiininiinillenlittZ%tillaili
3 FLOOR inialalinninlinalalail ininarii ' Vritii
4 FLOOR .0�.1����������.11.����r'. r����
63 FLOOR IIIIIIIMIWINIIMIIMIIIMIIIIINIMIN11111111111111111111111111tlaill111111•111111111111111111
FLOOR 1.11.11.1.11.11.1111111111111111.1111111111111111111111.1.1111.11.1.11.1111111.111.1.1111.11.
7
7 FLOOR intinallinniiiiiiininialannilliinalliniiinalinininal
S FLOOR EMEMMESo., if
Installing Company Name: J c c/o/e.- o , ,/ l s /�/Jee Check One Only Certificate
Address: 3c/ J Oco>.orSf City/Town: l M.✓L State: ' 'It 17 Corporation
Business Tel:,}`pp a3� - //? Fax ❑Partnership
Name of Licensed Plumber/Gas Fitter. ae/i toMe c kr
0 FInNCompary
INSURANCE COVERAGE:
I have a current Ilabilkv Insurance policy or Its substantial equivalent which meets the requirements of MOL Ch. 142 Yes 0 No 0
If you have checked In,please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy Er Other •
type •of indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER:I am aware that the licenses doea� the Insurance coverageereuired by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application walvee this
Check One Only
S, aturs of Owner or Owners _ 'em Owner
atlchecking rbbbox ■;(here0 Agent.0.__.. ..-----__-___
_Munlytataloft e details and In -------. . e .._.
of
all
.. -
compliance toaccurate whit the W Pertinent provision off eMMassachusills Sumbing tate Installations Plumbing Code andChapterunder the Mbareseedwd for�thN application w�lYeb�nU
142 d the General Laws.
ay of License: S �_
Plumber
nae
Gas Ftiter
Mas Signature of :caused Plumber/Gas Fitter
GtyITown Journeyman .
APPROVED OFFlC!USE CML LP Installer License Number: aha -7.‘