HomeMy WebLinkAboutG-12-061 •
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)Lryn �.�/
aaaa
LFJ —OZ r
_ ise f 2�01 / ) Mass. Date 20 /1 Permit A .2- r'9
:, la
F ook Lo kS/y•h 0 r roar' L
��` �� v Building Location /1 'CIE/ '� wner's Name
A JJ��,
‘'r • Owner Tel# Type of Occupancy /l e2 S
New 0 Renovation 0 Replacement Plan Submitted: Yes ❑ No oJ7
F URES
\]9 /��� N •
H '� JO I UG 0 i L011 =/
$1/jnv+7 w F. x o u " x i
o o w F a z6. 7 g 2 CUILOIR csan
1 i J i s u s m z By
g = 'o 6 s u n 3 c O 1 o g Q $ 12 O R
SUB-BSMT
BASEMENT •
1 rT FLOOR
•
2'0 FLOOR
3PD FLOOR
4T"FLOOR
5T"FLOOR
61"FLOOR
7T"FLOOR
81"FLOOR )
InstallingC/ompany,NameE`(2///1.Skit) Ail 4) Check one: Certificateat /
Address 0 7 4��,9 �l tie__ &C 22Sf (�
,(� / / orporation
-Sr jiAAf(4/1A%�9' /Tit 02641 o Partnership
Business Telephone# 57), 4 91 -7 77`j oFirm/Co.
Name of Licensed Plumber or Gas Fitter v �'rph-.e/) g '7/2/125/Yet.)
INSURANCE CO RAGE:
I have a curre lability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142.
Yes No 0
If you have checked Les,please irate the type coverage by checking the appropriate box.
A liability Insurance policy 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 0 i
Mass.General Laws,and that my signature on this permit application waives this requirement.
-•kc,,:
• Owner = •!en o
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered)in above a.,; .tion are , .n• accu = • I e best of my
knowledge and that all plumbing work and installations performed under the permit issued f• - applica • till .e In co • .nce with all
ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General a' -.
By Type of License:
•-Plumber Signature of Licensed Plumber or Gas Fitter
Title •Gas fitter % it�„q
✓Master License Number rLf g,
City/Town •Journeyman
APPROVED(OFFICE USE ONLY)