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HomeMy WebLinkAboutG-11-223 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING € au —y City!Town � . , MA. Date:_____ /_ permit" 61(.-- 2z3 Building Location: OF 5/1-�©N 4(L. Owners Name: C /(r tx,p,,,,„ G ?'Type of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional 0 Residential (piy New: 0 Alteration: 0 Renovation: Replacement: 0 Plans Submitted: Yes[ o 0 liLt ��� I FIXTURES • n` .) I [i 0 y N O et to e7'....:--) i ix o of i c-i n > re O N V 7p___ VO co O W X z O E = fj O i- O 0 1- 7 FOOQQl y W N W C. \ ce 0 2 --I 0 u- 1.. id I- ILI Id .1 t Ut U O O M 000u- 00x t7 = = m > O 33 O W.W Z Z W Q F=- SUB BSMT. X BASEMENT - 1" FLOOR 2N"FLOOR 3K"FLOOR 4" FLOOR 5'"FLOOR 6'"FLOOR 7'"FLOOR 8'"FLOOR 1 1 0 " ES A Check One Only Certificate# Installing Company Name: (�I �(X 2:1-Corporation Address c C 7QAqMPI1,e Th City/Town: tb giVAni State: Mt' 0 Partnership Business Tel: .50e 39S--80/1 Fax: 0 Firm/Company Name of Licensed Plumber/Gas Fitter: M f'A2-tz o 4jI�_ ACCEPTED , INSURANCE COVERAGE: CL W F- —$ I have a current'lability Insurance policy its substantial equivalent which meets the requirements of MGL.Ch. 142 Yes U No❑ If you have checked Yes,please Indl the type of coverage by checking the appropriate box below. A liability Insurance policy Other type of indemnity 0 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 0 Agent 0 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 Knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plum In Code and Chapter 142 of the General Laws. By Type of LI se: ❑Plu er �1n Title s Fitter Sig e o Lic sed P bed i er Master l Cityrrown ❑Joumeyman License Number: 100)40 if APPROVED(OFFICE USE ONLY) ❑LP installer