HomeMy WebLinkAboutG-12-196 1Rou LG-ft,S a t
1 o — 1 1- 1 l _f 2R.. -----
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
.ci
14
'7 �rl v ;( ' %/-O''raV -- — Date: Permit# 171- Ige•
,, Il F I City/Town:
�� ry`Y 4'S -sit) /,2OEL 2 'U� Owners Name: • en,
Building Locatlo. XResidenhal
If
. .
GType of Occupancy: Commercial' Educational ..a Industrial ,.,i Institutional
New: ' Alteration: Renovation: Replacement: Plans Submitted: Yes No,
FIXTURES _.__.—.
! en
s ix CC
Q
L cc ,
o i 7 ~ to til p Nto
Jft! CEIVE
.r o Zw Z 26-0 w = . UCS 1 1 �O1
O Lu
12.
U m L O W Z C7 W f- O Z 129 C9 Oen ,W Z W L______..
DlhG DE PT.
ooLLIOZO0 1= > 2 41-i 1.
SUB BSMT. — ----- -- --- - —i
BASEMENT
1' FLOOR
2NO FLOOR
3-rro-FLOOR ----
4'" FLOOR
5'" FLOOR
6 FFLOOR ---
7'" FLOOR __ —I
13'" FLOOR --- -
A filer/5a r Check One Only Certificate#
Installing Company Name:
/�1 //" �/ Corporation
Address: /9� !�Y �� City/Town; ����[r404.e.:1 State: MA
( /;4/ Partnership
Business Tel�7J - 6Pc. F
- Firm/Company.
Name of Licensed Plumber/Gas Fitter: . - r't f �wZ0 ..
INSURANCE COVERAGE: lvvvll�����` ___
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 Yes No
If you have checked Yes, please Indicate the type of coverage by checking the appropriate box below.
A liability insurance policy Other type of Indemnity Bond
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 A /
Owner Agent
Signature of Owner or Ow_oar's Agent '
By checking this box ;I hereby certify that all of the details and Information I have submitted ntered)regardin• •• ation are true and
accurate to the best of my Knowledge and that all plumbing work and installations perform oder the permit>, Is application will be In
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and apter 142 of the s.
,Type of License: �
By Plumber _ _
Title ,r - Gas Fitter Si• - , • itis�ber ...meter
Mester 42
(� �
City/Town Journeyman
4._ Number.
APPROVED(OFFICE USE ONLY) LP Installer