HomeMy WebLinkAboutG-12-358'` _ `
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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-tili-Y� >t City/rown:__� �f rt'f MA. Date: I ! I / Permit#C?2-3��J
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Building Location: / ners Name:___
GType of Occupancy: Commercial ❑ Educational 0 Industrial 0 Institutional 0 Residential LW'
New: ❑ Alteration: 0 Renovation: ❑ Replacement: 1/3" Plans Submitted: Yes ❑ No❑
FIXTURES
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SUB BSMT.
BASEMENT I
1" FLOOR
2"u FLOOR
3"°FLOOR
4'"FLOOR
51" FLOOR _
6'" FLOOR
71'1 FLOOR
8'"FLOOR _ -
Check One Only Certificate#
Installing Company Name: eL'CT,tf1,iJSk&a; _/A/C° . ____
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[Corporation .. 42..P/e%
Address:D ICEA/'eY:F/[;Wird. City/Town: t t: Zarioorte.3 7/ State: frit).
., rt C Partnership _
Business Tel: 5 G3=71277- 777 Fax: .514291- rf.-2,s
❑Firm/Company _
Name of Licensed Plumber/Gas Fitter: -.j /-1E1/0,4)/e/./ i`7. it.'%A"jte's''✓
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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{No❑
If you have checked Yesplease indicate the type of coverage by checking the appropriate box below.
A liability insurance policy ISI Other type of Indemnity ❑ Bond 0
OWNER'S INSURANCE WAIVER:1 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
Si.nature of Owner or Owner's A.ent Owner 0 Agent ❑
By checking this box •;I hereby certify that all of the details and information have submitted(o entered)re±-r• ng this applicat al.- true and
accurate to the best of my Knowledge and that all plumbing work and installatio .erformed under the per• it I .ue for this ap• ic. '.n will be In
compliance with all Pertinent provision of the Massachusetts State Plumbing Code. • Chapter 142 the en; al a s.
By_ Type of License:
0 Plumber \_
Title ❑Gas Fitter Signature of Licensed Plumber/Gas Fitter
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City/Town ❑Journeyman License Number: .Ar2/
APPROVED(OFFICE USE ONLY) 0 LP Installer