HomeMy WebLinkAboutG-11-697 •
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type) n q ''7
--1-- --r_-- / V. y�'i'k'Url� ,Mass. Date r(/l( 20 t'Permit//et( ' ( l
L Building Location Yr Wet//1pin G Owner's Name 6r1 C •
J.. N. Owner Tel# 7'7y-7-1r-1335—G Type of Occupancy il______K
aNew 0 Renovation 0 Replacement Plan Submitted: Yes 0 Noi
FIx7RES
� 1
RECEIVED
'Ego. co
zo a ADR 12tali
m w c E; a F
w W co JJw z ¢ F_F aW u F N : y a r 3UILDING DEPT
Z Q W d R' C N E N r7 2 O Z it o ro c 6.
- z Ji7 r tL' 6 3 o c`7 `a 8 a ' .- E b - C C •
SUB-PSMT _
N BASEMENT
1s FLOOR
2NDFLOOR
G..,, 3R0 FLOOR
4TH FLOOR _.
,... 5TH FLOOR .. ...
. 6TN FLOOR I Y ;oc
8�"FL.00R p -.
Installing Company Name _IISTy IS Twc. . Check one: Certificate
Address x2.2 Mid—Tedi On✓c- Corporation 1762. C
War- Qvn1 MA 02473'• 0 Partnership
Business Telephone#_•S0$'-775-'1303 "-"-I ` . LiFirm/Co.
Name of Licensed Plumber or Gas Fitter FRAttIK Loden x
INSURANCE COVERAGE: • •
I have a current ilability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142.
Yes No ❑
If you have Icked y ,please Indicate the type coverage by checking the appropriate box. .. - - .
A liability insurancePolicy'X. Othertype 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
Mass.General Laws,and that my signature on this permit application waives this requirement.
. .. Check one: '_i;. '
- - -' Owner 0 Agent ❑
Signature of Owner or Owner's Agent c,•- - - •- -'- ,
I hereby certify that all of the details-and information I have submitted`or entered)i4 above application are true and accurate to the best of my I
knowledge and that all plumbingwotk and Injalletions performed'under the permit Issued for this application will be In compliance with all. -.••
•erti:t •rovisions of the assa &setts State Gas Code and Chapter 142 of the Genet ws:---- - I -1 , 1 I ,( i 1
y ,
,e-- i I .�'/
BY 1•_..�s���, I !Type of License' I �... I Mme...i/V r� � r ; ,
1 . -r- Plumber - Signature of Licensed Plumber oWGas Fitter; • `. - - "' i' .
Title tV - tat_.ir. 1 jsfiitter ' '' --'- ' . - n . I _i
i License Number '77 •
City/Town •2�.Ar. ir_.� ..._®anI _. .
APPROV D(OFFICE USE 0 LY) • -