HomeMy WebLinkAboutG-12-226 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type) `1
t' M e1 YVl mfl�� ,Mass. Date /a/'/7 20 // Permit — '
l: =55g ZN�//7l9///lel J�I fiek _ / til/')
Building Location / O ner s Name
s..;. Owner Tell/ 96-0 7/+' w ' Lva Type of Occupancy
New 0 Renovation 0 Replacement 2. Plan Submitted: Yes 0 No
FI ORES
[EES ' g
G41-0r o
i_ OrT 18 2 011 =/
� yy aazs Fy - . —
t igeO i F a 11 ° i EN
40.3 POO
* roam ago O
SUB-BSMT I
BASEMENT
1^FLOOR '
2He FLOOR
3"e FLOOR
4TH FLOOR -
STMFLOOR
BTM FLOOR
7T„FLOOR'
' 8TM FLOOR _
Installing Company Name l•e///CJs/L�/(� �"� 71 Check one: Certificate ` _
Address 0 7?C4.ede 9 / ,6/'L— P•�o/rpsCoration TT�iiy! £L
Yearn Ath Iiiiz c266/ a Partnership
Business Telephone# 9 rP) t O( / 776 U //1� //ltaFirm/Co.
Name of Licensed Plumber or Gas Fitter S'f/0h-e/) ' ✓ .w/'r/�'c,hip
INSURANCE
ERI have a currbility
insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142.
Yes No ❑
If you have checked des.please cats the type coverage by checking the appropriate box.
A liability Insurance policy Other type of Indemnity o Bond 0
OWNERS 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 waives this requirement.
Ck o•-:
• . er = •ent 0 /
Signature of Owner or Owner's Agent
I hereby certify that all of the details and Information I have submitted(or entered)in abo , ••libation ar true an• 'ccu - e a the•: • my
knowledge and that all plumbing work and installations performed under the permit Issued for th -•tir on will •- • pliance • all
ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
13
By Type of license:
•Plumber Signature of Licensed Plumber or Gas Fitter
•
•Title Gas fitter 42.2-11g).�tdaster License Number iC/
City/Town •*Journeyman(OFFICE USE ONLY)