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HomeMy WebLinkAboutG-11-860 e-ti-s $Es'I- ©v__ to - a 2 ( ( YztZ. MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING ain =118r City/Town: ( t/- �ctr+ o MA. Date: +�Q// P ermit# 01( Q(10 p- Building Location:-?G 44 6 -f 1 Ceq /41-"/41-"-e- Owners Name: /4/471- G Type of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional 0 Residential New: ❑ Alteration:0 Renovation: 0 Replacement: 0 Plans Submitted: Yes 0 No 0 -- py FIXTURES yyl M uiK Z Y F ui JUN 22 201 z re 4-) x z LaiI ~ >9 Cy WW "�Z F Q _ OFFj CO }WQWO6 g (- in GUID:NGOEFTO N ui Q CCY y Z y V y ULL n / Sr 2ayJ - Ow2y ~ W2es 0z0 if,g SUB BSMT. BASEMENT 1a`FLOOR 2N'FLOOR 3K0 FLOOR 4'"FLOOR 5'"FLOOR - 6"FLOOR 7"FLOOR 8'"FLOOR installing Compan Name:SC ori r @L -1�;' Check One Only Certificate# er�,�e ID„((JJ / Corporation Address (R .vir Grp. City/Town: 11°.% r.c'(1 State: r 0 Partnership Business Te��eC 4jd, ?79” Fax: -` ❑Firm/Company Name of Licensed Plumber/Gas Fitter: Ca'T/4iregt'Ser) 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 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 Signature of Owner or Owner's Agent Owner 0 Agent 0 By checking this box 0;I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be In compliance with( itall Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Si /Type `_ By '�_I T lumber Tine 1W s} yL' • ' r 0 Gas Fitter a` �d" sed• Plum e�� t� Gas Signature of Licensed Plumber/Gas Fitter City/Town 1 . ❑Journeyman License Number: pL APPROVED(OFFICE US ONLY) 0 LP Installer /07 !