HomeMy WebLinkAboutG-11-257 It
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/�(9 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
' `P b\� _-c/ Cltyfrown: 1 0 .� 0"Ob 3 (ti l .MA. Date: /0/0 Permit# I I"
Building Location: 7 h .S'/, !We/ /2 of Owners Name: /7/4. /,'f
GType of Occupancy: Commercial 0 Educational 0 Industital 0 Institutional 0 Residential
New:0 Alteration: 0 Renovation:0 Replacement 0 Plans Submitted: Yes 0 No[VI
FIXTURESitn\liI 0tden
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BASEMENT '
15' FLOOR
2""FLOOR
3""FLOOR
4'"FLOOR f1
S"1 FLOOR
8'"FLOOR Fit �...+�'i
7'"FLOOR
8'"FLOOR
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Installing Company Naame:�4),, ot„ P S 5-2Chock One Only Certificate#
(Pit u.7� l rf 1 1/ 0 Corporation
Address:
City?own.�j U�cv Ski' State: t
Business Tel: S�1fl'- . ci3<I ❑Partnership
Fax:
Name of Licensed Plumber/Gas Fitter.e_ 1 S Flrm/Comparty
INSURANCE COVERAGE: —
I have a current Ilabillty Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 Yes Ly"No 0
If you have checked Ieg,please Indicate the type of coverage by checking the approprtats box below.
A liability insurance policy 13// Other type of indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not jun 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
Signature of Owner or Owner's Agent Owner 0 Agent 0
BY candling 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
heeMeassachusetts State Plumbing Code and Chapter 142 of Me General Laws.
By ❑pPI fmLic w: 1 c
Me Fitter Signa ure of Licensed Plumber/Gas Fitter
aster
City town ❑Joumeyman License Number: 'SO48
APPROVED(OFFICE USE ONLY) 0 LP Installer