HomeMy WebLinkAboutG-11-097 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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c = .l.-� Ci /Town: 7 S14:06 Permit#61 -riaL.
. _' ty e/121r1_LJ MA. Date:
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J"i4 Building Location: #1 I / _; 1 - Owners Name:�l/?/NE j7ZLL/C
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Type of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional 0 Residential
New:❑ Alteration: 0 Renovation: ❑ Replacement: Plans Submitted: Yes❑ No 0
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SUB BSMT.
BASEMENT
1" FLOOR
2N3 FLOOR
310 FLOOR -
4'"FLOOR
5'"FLOOR &C„EP1EO
6'"FLOOR
7T FLOOR B
8'"FLOOR
Check One Only Certificate#
Installing Company Name: E.F Wids-Low /fl C
17 ,Corporation 76 _
Address:. &lc`A€AW A&ZECity/Town: S', fr101)1X State: MA
❑Partnership
Business Tel: 50?' ? 7J7B _ Fax: S08^3gii-_ 52.51.,
o Firm/Company _
Name of Licensed Plumber/Gas Fitter: E. F. L4//y1VSLOU) .77-TE:
INSURANCE COVERAGE: •
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes® No 0
If you have checked Yes,please Indicate the type of coverage by checking the appropriate box below. (L
A liability Insurance policy M 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
Owner 0 Agent 0
i Signature of Owner or Owner's Agent
By checking this box❑;I hereby certify that all of the details and information I h. . ..miffed(ore. ered)regarding i .pplicatlon are true and
accurate to the best of my Knowledge and that all plumbing work and Installati• 5 pe.• m d unde• a permitJaw••f. this application will be In
compliance with all Pertinent provision of the Massachusetts State Plumbing :•e.'. Ch pter 14- of the Genera t-,
/ day/l/
Type of License:
By 0 Plumber
Title Gas Fitter Signature of Licensed Plumber/Gas Fitter
0 Master
City/Town ❑Joumeyman License Number: '7939
APPROVED(OFFICE USE ONLY) 0 LP Installer