HomeMy WebLinkAboutBLD-12-367 Sess
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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-•.�<_ . City/Town:Wr GLrit40 a 7-1-1 , MA. Date: /2 -/S.- // Permit/SOIL- 367
Building Location: II) c fit-re y I.Qra/o' ' Owners Name: &4,-4./
GType of Occupancy: Commercial 0 Educational 0 industrial 0 Institutional 0 Residential f
New:0 Alteration:g" Renovation:0 Replacement 0 Plans Submitted: Yes 0 No RI
FIXTURES
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SUB BSMT.
BASEMENT
FLOOR
21°b FLOOR
en FLOOR
41"FLOOR -
Su'FLOOR
8'"FLOOR - -
7'"FLOOR
S'"FLOOR
Installing Company Name: a,l,e et ildp�P en,- #O r Check One Only Certificate 0
Address:.2.3 £oweisiA eeri U'f City/Town: dMad4 I"G State:r. A El Corporation
Business Tel: Cog !{ ❑Partnership
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Name of Licensed Plumber/Gas Fitter. 1.tre -- ��� �Fin"�omparry
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 Igg,please Indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy gr Other type of indemnity 0 Bond 0
OWNER'S INSURANCE WATER:I am aware that the licensee does not haw the Insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waive this
! rsqulremerd.
Check One Only
Signature of Owner or Owner's Agent Owner 0 Agent0
By accurate kin this O:I hereby certify that all of the details and Infonnaaon I have submitted(or entered)regarding this application are true and —
compliance with all of m K ledge and that all plumbing work and Installations performed under the pens issued for this application will be In
Provision of the Massachusetts Stab Plumbing Coda and Chapter 142 of the General Laws.
By
Type of License:
PlumberG •
line ®'Gas Fitter Signature of L censed Plumber/Gas Fitter
O Master
cayrtown BJoP Inumstallersyman License Number V/3 g
APPROVED(OFFICE USE ONLY) OO L
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