HomeMy WebLinkAboutG-11-316 ��. MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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SII_ • CItYlTown:1��011 ' /
M Date: 1 U Permit/ l— 3
Building Location: O� ! • Op.� . 4
G Owners Name:�UIil�O v/ '�'
Type of Occupancy: Commercial 0 Educational 0 Industrial 0 institutional 0 Residential fl
New:❑ Alteration:0 Renovation:0 Replacement a Plans Submitted: Yes❑ No
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Installing Company Name: deck «aye a Check One Only Certificate
Address:3 C{ of City?own. - /, ❑Corporation
Stab:
Business Tel 9 4 - e ❑Partnership
Fax:
Name of Licensed Plumber/Gas Fitter. G c kCa h C [ FlmtlCompsrry
INSURANCE COVERAGE:
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I haws current liability htsuraoce policy or Its substantial equivalent which meets the requirements of MOL Ch.142 Yes[Cita❑
if you have checked igg,please indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy a_ Other type of Indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee don not haw
Massachusetts General Laws,and that my signature on this permit applicationf Insurance this requirimme ul�by
Chapter 142 of the
Check One Only
S .nature of Owner or Otvne/s •ent Owner ❑ Agent gent - -- - —
... ._ By checking this box •;thereby certifythatthe - - -- -- ------------------_--
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accurate to heel ofan • and Information than submitted or _
campfire*with all Pertinent provision Knowledgeian of the MassachusetbMat aN plumbing work andState Plumbing Codenstaltations Chapter ap1entered)
nem*
��tng this his application tion will be In
ar 1• of License:
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ria 4' •
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nes M a Signatu • ken edPlumber/Gas
Fitter
citR : ouIn r� --� 75-1/43-
APPROVED
OFFICE LME Ott. • LP Installer License ben O: