HomeMy WebLinkAboutG-11-873 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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E ',7:11,==-- : City/Town: 7�IU t IOV ! 41 I r e
la_M l MA. Date: l�/ Permit# 0 7�
Building Location: 9,rSt/U,\SES t ( 7ftt Owners Name: £i 1/e to 19i OM
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G Type of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional 0 Residential
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New:d Alteration: 0 Renovation: 0 Replacement: 0 Plans Submitted: Yes 0 No❑
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Installing Company Name: Check One Only Certificate#
GHECKOWAY ENTLHPRiSLS 0 Corporation
Address: 11 QVU1LL ROAD State:
DEWS,MA 02638 0 Partnership
Business Tel: 508-385-1031c:
F irm/Company
Name of Licensed Plumber/GasFitter:
P.. PETER CHECKOWi2 i
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 Yes Lor No 0
If you have checked Yesplease indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy Ili Other type of indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
Check One Only
Signature of Owner or Owner's Agent Owner 0 Agent 0
By checking 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 p- k Issued for this application will be In
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of_„?rGeneral Laws.
By Type of License:
[PU!
lumber
Title EJ Gas Fitter Signature of Licensjmber/Gas Fitter
We aster
City/Town ❑Journeyman
License Number: l 75'0
APPROVED(OFFICE USE ONLY) 0 LP Installer