HomeMy WebLinkAboutG-11-074 (5 Simpson Avenue) II@El0 117
AUG 0 2 RECD
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
rm tire,_ (Print or Type) , / �Bjy'� �/� [
�� -C CM e/�( ass. ate ��pc d� 20 /6 Permit # 6�1 0 / 1
t o-_ i Building Location tea(/ � Owner's Name2%......rr� C
S-m Yc/l/ ate • Type of Occupancy
New ❑ / Renovation 0 Replacement k Plans Submitted: Yes❑ No ❑
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SUB—BSMT. ,
BASEMENT
QST FLOOR , _ -. _ I 1 _
2,413 FLOOR _ 1 J
3RD FLOOR _
4T14 FLOOR . I 1
ACCEPTED W
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Installing Company Name r/ V Check one: Certificate
Address /43 ,'• • i 4., a A " • Corporation
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0 Partnership
Business Telephone 7 7r- V C i ce �/� D Firm,Co, c� p
Name of Ucensed Plumber or Gas Fttter a6 �I��/ ooZiZO �' C_ 3
INSURANCE COVERAGE:
I have aY ❑ Insurance
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current liability nsua ce policy or Its substantial equivalent which meets the requirements of MGL. Ch. 142.
If you have checked yes. please Indicate the type coverage by checking the appropriate box.
A liability Insurance policy 0 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.
Check one:
Owned] Agent 0
Signature of Owner or Owner's Agent =
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I hereby certify that all of the defogs end information I have submitted(or entered)in abov aai�. • of my
knowledge and that all plumbing work and installations performed under the permit' •''.., • . `• " raw with all
pertinent provisions o1 the Massachusetts State,Gas Code and Chanter 112 0li'
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