HomeMy WebLinkAboutG-11-526 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
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f �y eA- YARMOUTH-- ,Mass. Date&� 20 1 l Permit# Q1 c—c2
=` 1 Building Location 1 t34 3al"Rt F'7U1c Owner's NamegL/{IV(4[ f-�')
ea 6 Owner Tel# '7 l'23 51 S 2415 Type of Occupant
New 0 Renovation 0 ReplacemenX Plan Submitted: Yes 0 NoX
FIXTURES
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ggh gy ogo 0 E 3 a u 3 8 c `0
SUB-BSMT
BASEMENT x
1'r FLOOR
2ND FLOOR
3RD FLOOR
41"FLOOR
5'FLOOR
6T"FLOOR
7TH FLOOR
8"FLOOR •� j
Installing Company Name.E�>t et'1175/6k) �_/T 7? Check one: Certificate jr,
Address P2 �f� /2) (it'll/C. / / corporation %ghat C.
c--;_iii ni;L/S�h�7'Met 09vU/ ❑Partnership
Business Telephone# '57th 3Y T -7 7 7`J d..)//).
0 Firm/Co.
Name of Licensed Plumber or Gas Fitter � /�Tr%oh-e/) /y •d..)/1).5�'/0
INSURANCE CO RAGE:
I have a curre lability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142.
Yes No ❑ ACCEPTED
If you have checked reLq,please iwte the type coverage by checking the appropriate box.
BY:
A liability Insurance policy Other type of indemnity D Bond o
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Mass.General Lawst end that my signature on this permit application waives this requirement.
Check spe:
Owner or Agent a
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered)In a•• e applicati••?re true and rate the best of
knowledge and that all plumbing work and Installations performed under the permit Issued • • ap,'cation will be I ance with all •
ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By Type of License:
•'Plumber Signature of Licensed Plumber or Gas Fitter
Title •Gas fitter 7.24,2-93
��JA9,
93
•�vtaster License Number
City/Town •'Journeyman
APPROVED(OFFICE USE ONLY)