HomeMy WebLinkAboutG-11-844 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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fir-a: City/Town: "/4-1141f / MA. Date: /t / Permit#61'I—p L
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Building Location:/1 ✓/ Si Owners Name: 72err MP'41174"
G Type of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional❑ Residential •
New:0 Alteration:4 Renovation:❑ Replacement: ❑ Plans Submitted: Yes 0 No❑
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SUB BSMT.
BASEMENT _
lei FLOOR
2N'FLOOR
3"O FLOOR
41"FLOOR _
5'"FLOOR
6"FLOOR
7'"FLOOR
8"FLOOR
64•92- �D M��/ Check One Only Certificate#
Installing Company Name:
/" /� 0 Corporation
Address: 19-
ie/`/ w�/ •
City/Town: J f V�/��4 State:)414
0 Partnership
Business Tel: 6-0 Y 39 q 15a I Fax:
❑Firm/Company
Name of Licensed Plumber/Gas Fitter: 4/ elf.CS9ti d
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.
A liability insurance policy 0 Other type of indemnity ❑ 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 ❑ Agent ❑
Signature of Owner or Owner's Agent
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 Kno dge and that all plumbing work and Installations performed under the permit Issued for this application will be in
eo Ila a with all P:. nent pro``-Ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
`' Tye�of License:
By /' r - I�Plumber e/�
Title W 5 f � 0 Gas MFer Signatu of Licenses ePlumber/Gas Fitter
Cityrrown iilelleaov ❑Joumeyman License Number: l��a<j
APPROVE (OFFICE USE 0 L 0 LP Installer