HomeMy WebLinkAboutG-11-302 uursr : /4/ PARCEL : ne„. 3
\ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFIr T ING
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Installing G rnpany Name Rusty s Inc Dr Check ont ff
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Address 222 Mid—Tech Drive- t Corporzton 1762—C
West Yarmouth • E. partnership .
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Business Telephone 508-775-1303- D Flan/Cc.
Name of Ucensed Plumber or,Gas Fitter Frank W. Roderick _ ,
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INSURANCE COVERAGE:
• I have a cu.-erg. I• -fitly insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. .
Yes No ❑
If you have•checked yes. pleeassee I, irate the type coverage by checking the appropriate box.
A liability Insurance policy VG . Other type of indemnity 0 • Bond ❑
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 wah,+es this requirement.
Check one:
Owner Agent ❑ .
S.gnature ci Owner or Owner's Agent - - -
1 hereby pertrtend that all of the details' Information I hays'submitted (Or entered)in above application vs true and c=urate to the est of my
• knevean:that cI'piumbinwore and installations performedunder thepermit/ni wibe in rompwith all
pertnent proy'scs ptthMassachusetts Stele Code and Onxpler 142 of tegneral LiwwI i 1 T '', "
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I ' umber ;nature Ci Licensed PVUm't ! or CuCas fl ,_+ t +
Title _ NIG - itter ; ' "�
: t license r
• � ',aster -- Number 7794
atyrrown .a Journeyman
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