HomeMy WebLinkAboutG-11-185 :• ,,,,"r;--__ APPLICATION FOR PERMIT TO DO GASFITTING
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�0�'O/( (} PERMIT NO. / J
Date it M.
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Type of Occupancy igf/oen 7/et_
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Newa- Renovation ❑ Replacement❑
Plans Submitted Yes❑ No❑
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SUB-BSMT.
BASEMENT I 1
1ST FLOOR
2ND FLOOR
3RD FLOOR
(PRINT OR TYPE) Check One: ACCEPTED 9#-
Installing Company Name Cl ILCKOWAY ENTERPRISES ❑ Corp.
Address 11 SCARGO HILL ROAD ❑ Partnership
DENNIS,MA 02638
508 385 1911
:PIrm/Company
Business Telephone �'. PtTEK CHECKOName of Licensed Plumber or Gasfitterw
INSURANCE COVERAGE: Check One
I have a current liability insurance policy or its substantial equivalent. Yes ig No 0
If you have checked yes, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy ' t 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 One:
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted Cat of Licensed
(or entered) in above application are true and accurate to the best of Plumber or Gasfitter
my knowledge and that all plumbing work and installations performed / 3 (// 7
under Permit issued for this application will be In compliance with all
pertinent provisions of the Massachusetts State Plumbing Code and License Number
Chapter 142 of the General Laws. TYPE LICENSE:
[$'Plumber 0 Gasfitter&Master 0 Journeyman