HomeMy WebLinkAboutG-11-808 4t 4
t MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
fig_ Ctty/Town: MA. Date: �t l �+
`•Y .` (�� Permit#L9
Building Location: t i t1 E I �)NcS I'tJl J O P� Sx n)
Owners Name: NO
GType of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional 0 Residential
New: 0 Alteration:0 Renovation:0 Replacement:
tr Plans Submitted: Yes 0 No 0
FIXTURES
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SUB BSMT. IIIIIMIIIIIMINIMINIIIIIMISIIMISINIIIMINIIMIMIIIIIMIIMIIIMM11111.1111101111
BASEMENT 11111111•11111111M111•11111111111111111111111111M1111111I11111111111111101•110110111111111
1 FLOOR .11.1111111111.1111110.11111110.11.1101.1.11.11inlE11.1111111111.111111.1.11.1
2 FLOOR INIIIIIIIIIMINIIIIMIIIIIMIIIIIIIIIIMMEMIMIIIIIIMIIIIMINIIIIIMIIIIIMIal
3 ' FLOOR IMIIMIIIMIIIIIIIIIIII1111111111111111111111111111111111111111111111111111.111111111111111111111111111111111
4 FLOOR 1111111111111111111111111111111111111111111111111111111111111111111111111111111011111111101011MIS
5 FLOOR IIIIIMIIMIIIIINIIMIIIIIIIIIIIIIMIIMIMIIIIIIIMIIIMIIMIMIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIMNIIII
6 FLOOR NiallinaiiMinnaill11.11.1.1.1.111.1.1.11111.1.111111110.0.1MIMME
7 FLOOR 1111111011111MNISIIIIMMIIII11111111111111111111111111111111111111111111111111111111111111111111111111
8 FLOOR 111111111111111EISIIIIMMIMMIIIIMINIIMISIMM11111111111111111111.11111110111111111111N1
Installing Company Name: cuFrirnurev rnircoome Check One Only Certificate#
CI 5SCCAl5` AD
Address: HILL ❑Corporation
-b}A- 33__ State:
Business Tel: 508-3 .�gt1 0 Partnerehip
Name of Licensed Plumber/Gas Fitter: �Firm/Company
a ; CHECKO)NA�
INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 Yes-No 0
If you have checked Yes,please Indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy b Other type of indemnity 0 Bond
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 wave this requirement
Check One Only
SI.nature of Owner or Owner's A.ent Owner 0 Agent 0
By checking this box ■;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 • rink Issued for this application will be In
compliance with an Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142y General Laws.
By Type of License: �i'
DI Plumber umber
Title
0 Gas Fitter Signature of Licensed .1'mber/Gas Fitter
0 Master
City/Town ❑Journeyman 1 74/1 ^
APPROVED OFFICE USE ONLY 0 LP Installer License Number: J l/ /