HomeMy WebLinkAboutG-12-021 1 �
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type) /�11
_ ar 1 14400 t i? ,Mass. Date l')7- I/ 20 /I Permit 412—8.41
Building Location JVD ,e i' ref 1(4 - Owner's Name KO/ /
f^ 21
11160090 vll/T may/
e4•� • Owner Tell/ �s3— / ... // 1 -/2.7 -R Type of Occupancy ,(9.S
New 0 Renovation 0 Replacement/c Plan Submitted: Yes 0 No
FIXTURESGr
etoca
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v Wl rn w z_ zz ,d {2 u73 g x 13 JILL SNC DE
z h a l: F y C7 4 ..1 N 3Y'__ _ — J
h `= o 0 i n. 3 ci u l °u g i $ k'
SUB-BSMT
BASEMENT /
1°i FLOOR
2"D FLOOR
3RO FLOOR
4"FLOOR
5"FLOOR ,
6T"FLOOR
_ 7T"FLOOR
8T"FLOOR / /}
Installing Company NameEfri,��//7s/0/0 ,4-/?r t2 Check one: Certificate
Address 0 7321-27,6264 ete— / / trcorporation 3eS/ Lt.
34'fl/i'�i1ih�7'////� 7r7966/ ❑Partnership
Business Telephone# 3T)CJ -;. Q 91�"7 7e ��) 0 Firm/Co. )
Name of Licensed Plumber or Gas Fitter v ,O/7-E/) g •LJ)ii25 9i;(
INSURANCE COyERAGE:
I have a curre lability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142.
Yes No ❑
If you have checked ,please tate the type coverage by checking the appropriate box.
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
Mass.General Laws,and that my signature on this permit application waives this requirement.
Check o•-:
• • •- '. Agent ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered)in ab• - _••licati.f are true• • a rate to _ •=sl of my
knowledge and that all plumbing work and Installations performed under the permit issued forth s.Cplication I e I compile : Ith all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General La
By Type of License:
••Plumber Signature of Licensed Plumber or Gas Fitter
Title •Gas fitter
•M 7: /J /,
aster License Number .f—E
City/Town •Journeyman
APPROVED(OFFICE USE ONLY)