HomeMy WebLinkAboutG-12-353 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
fa, 55W City/Town: ____ aint _ MA. Date: /2-/6-4 Permita L— 353
Building Location:1/ 779 walk.y�_bje_ Owners Name: .f)d/1/ £' m m c✓E4
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morx pons
G Commercial of Occupancy: Commercial ❑ Educational 0 Industrial 0 Institutional 0 Residential,
New:0 Alteration: 0 Renovation: 0 Replacement: Plans Submitted: Yes 0 No❑
FIXTURES
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SUB BSMT.
BASEMENT I
1" FLOOR
2Nu FLOOR
3Nu FLOOR
4'" FLOOR
5'"FLOOR
6'"FLOOR
7'N FLOOR
8'"FLOOR
_ Check One Only Certificate#
Installing Company Name:_, .TL1_/vk &z r//Vc'_ . ____
/e fry ., [Corporation g.;j; '/
Address: t- tlye C nett er City/Town: J: ii-1, /Jle2,i/ State: frit:,.
. ort, ❑Partnership
Business Tel: .6-e5"-.:579/- 777f Fax:_Stir- fas e• —
❑Firm/Company _
Name of Licensed Plumber/Gas Fitter: -_,0 i e>O g,y' N. r'L'2/ij Ci�6,:
—
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 ti 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
Owner 0 Agent 0 /
Si.nature of Owner or Owner's A.ent
a
By checking this box •;I hereby certify that all of the details and information I h- - •mitted(• entere• rega ding this applicatio .re e and
accurate to the best of my Knowledge and that all plumbing work and Installa •ns performed under the •ermit ssued for this appr alio• will be in
compliance with all Pertinent provision of the Massachusetts State Plumbing Co•. . .• hapter y of the G- or- aws.
Type of License: —
By------- ---- 0 Plumber �l�
Title ❑Gas Fitter Signature of Licensed Plumber/Gas Fitter
— Master
City/rown __ _ _
['Journeyman t^
APPROVED(OFFICE USE ONLY) 0 LP Installer License Number: , �.(,�.�,;__-_