HomeMy WebLinkAboutG-11-328 - MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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BuildingLocaton: `t2 Sc,44p((t. I V!
G Owners Name: �1'1J r1 )���=-
Type of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional
0 Residential,®
New:0 Alteration:0 Renovation:❑ Replacement:W Plans Submitted: Yes 0 No
FIXTURES
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3 . FLOOR .151. .1.0.0.111.1.1111111.1.1011.11.1111111111111.1.1a1111.1.iiiii.
4 FLOOR Malill11111111111111•111111111111111111111111111MINIIIMININ1111111111111111111111111111111111
S FLOOR in110111111.111011.11.111.111.11.111.11.11.11.1.1.11.11.111C112111111.111111.1
S FLOOR allallinlininn.11.111111.1111111111111MilaninnInniali.11.11It•„!rir
7 FLOOR 1111111111111111111111111111111111111111•111111111111111111111111111111111111L'1tC.'�rIIIIIIIIIIN
8 FLOOR 11111111111•1111111111111MMISI -N11111111111111111101111111.1111111111IIIIMMIIIIIIMIIIIMIIMI
Installing Company Name: rti� i7 iUKy4Check One Only Cec
Address: to SyV HtSF (1� 1-2 (`ItylTown:�Nyti yLw 6- 0 Cion
State: ttA .
Business Tel: ?7V-212 . gag Fax: ❑Partnership
Name of Licensed Plumber/Gas Fitter: twM. 1_ us
0 FImVComparhy
INSURANCE COVERAGE:
I have a current flaninsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 Yes13 No❑
if you have checked's)please Indicate the type of coverage by checking the appropriate box below. T
A liability insurance policy$ Other
type of Indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not hawthe l
Massachusetts General Laws,and that my signature on this permit applicat is coverage required by Chapter 142 of the
Check One Only
S 'nature of Owner or Owners .ent Owner
----- BycheckingNb box •■;I hero - _ 0 _Agent ❑--_._----- -_-
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d dMMper permit
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Maaaachuselta Stab Plumbing Cala and Chned apter 142 d IM n ,ems this apptlaton wltl be In
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By of license: vv l
Plumber
nue Gas Fitter
Master Signature of Licensed Plumber/Gas Fitter
APPROVED- 41-OFFICE U!!OInstaller License Number: 08c3