HomeMy WebLinkAboutG-11-241 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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= r(_ _• Cltyfown: )�A2athal MA. Date: to �/0 P•nnit#�a I( Zl�/
Building Location: a 3 7 , -lad ,,
Owners Na
/ ortAgo me: J�✓E2PE p/ /�!
G Type of Occupancy: Co mercials Educational 0 Industrial 0 Institutional 0 Residential 0
New:0 Alteration:0 Renovation:0 Replacement$11 Plans Submitted: Yes 0 No
FIXTURES
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Installing Company NakQ t Alt'cf°I Se 1 Check One Only Certificate N
Address:/IcJCd � 1me:�1`�� C N 0 Corporation
State/r
Business Tel: Sig 31/ rd
Fax: , l'YBJ--oS 0 Partnership
Name of Licensed Plumber/Gas Fitter. ; E CHECKOWAYta ID-Finn/Company
INSURANCE COVERAGE:
I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142 Yes b'No❑
If you have checked's',please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy a• Other type of Indemnity 0 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 waive;this requirement.
Check One Only
S ••nature of Owner or Owner's •tint Owner 0 Agent 0
By chocking this box ■;I hereby certify that al of the details and Infomntlon I have submitted(or entered)regarding this application are true and
accurate to the beet of my
wled a and that all plumbing work and Installations performed under the permit issued for this application will be in
o
compliance with all Pertinent of the Massachusetts usetts Stab Plumbing Code and Chapter 142 of thee„)eral Law,.
BY of license: /
Plumber
The ❑.Gas Fitter Signature of Lic need PI �y�T'�r/Gas Fitter
Master
City/Town ❑Joumeyman / l
APPROVED OFFICE USE 4--3--a. ❑LP Installer License Number:
Jj �.,�oacc rn1eFF�1'['ION(Sl
FIN AL INSPEC77ON BELOW FOR OFFICE USE ONLY
FEE. f PERMIT#
APPLICATION FOR PERMIT TO DO,GAS FITTING
Liar s TYVF"`_ OF BLlLBING
r isigl N OF BUILDING
SKETCH
n Ln.RFR CASFPITFR 1?INSTALLER
LICENSE NUMBER:
PERMIT GRANTED 0 DATE:
GAS FTITING INSPECIIOR