HomeMy WebLinkAboutG-12-379 lf: . MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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_°,:i. City/Town: Si /0 Amo Le ,MA. Date:/1o�//,a o» Permit/9 GI 2-- 37`t
Building Lo 6 O 7
S/1,4,1 ow r"../ LJ Owners Name:--„, f/1�AZel jle//
GType of Occupancy: Commercial 0 Educational 0 Industrial 0 instl�utlona!❑, Residential V
New:0 Alteration:0 Renovation:0 Replacementr Plans Submitted: Yes 0 No 0
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SUB BSMT.
BASEMENT
1a'FLOOR
2"FLOOR
3TM0 FLOOR
4'"FLOOR
S'"FLOOR
6'"FLOOR
7'"FLOOR
S'"FLOOR
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installing Company Name:4,�en 4"Ig A'�_B Cheek One Only Certificate#
�ao /PI/ 0 Corporation
Address
!y'//c City/Town:C4 State:44a„
Business Tel:749.--,-1- 4g 4 Fax:
0 P� erahip
C'3 FInnICompany
Name of Licensed Plumber/Gas Fitter:/7J46/ .7c/Z6/4„0
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL Ch.142 Yes❑ No❑
if you have checked In,please indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy E3k7 Other type of indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee dd nod j!d•es reed h the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waive,this requirement
Check One Only
Signature of Owner or Owner's Agent Owner 0 Agent 0
By checking this box U;I hereby certify that atl 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 perms issued for this application will be In
compliance with all Pertinent provision of the Massachusetts State Phunbing Code and Chapter 1 of the General
•
By pe of lcenw:
Plumber '---#111°In7
Title Gas Fitter Signature of Licensed Plumber/Gas Fitter
Master
Cown �Joumeyrtler Licensean
Number: ‘r
APPROVED(OFFICE USE ONLY) LP installerd