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g , MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING p,
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a "; City/Town: Y4/21/Ve E M MA. Date: e- P."/)-- Pe-rmit#it^133-3
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Building Location:to Y ezve 1 y�/}i/eel Owners Name: m/Moie �yj ,
GType of Occupancy: Commercial❑ Educational 0 Industrial 0 Institutional 0 Residential
New: a Alteration:0 Renovation:E -Replacement: ❑ Plans Submitted: Yes 0 No 0
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SUB BS T.
BASEMENT
15r FLOOR / /
•
2NO FLOOR / 4771 G
3Hu FLOOR
4'"FLOOR
51"FLOOR - -
6'"FLOOR
\ 7'"FLOOR
8'"FLOOR
(\ Installing Company Name:/2 abwmfr7'. Check One Only Certificate#
,n'\ Address: >7-i hi/u/00oe /Town: 4 n tate: /f/7}
0 Corporation
` Business Tel:s6c -5-09^ 900/ Fax: 0 Partnership
0 Firm/Company
Name of Licensed Plumber/Gas Fitter:
INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142 Yes d;0
If you have checked Yes,please indicate a type of coverage by checking the appropriate box below.
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 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
Check One Only
Signature of Owner or Owner's Agent Owner 0 Agent 0
By checking this box 0;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 permit Issued for this application will be In
compliance with all Pertinent provision of the Massachusetts State Plumbing a and Chapter 142 of the General Laws.
By Ty ye of License: JA /f7V//
IQ Plumber ( '
Title ❑G Fitter a e of Licens Plumber/G. )1r -r
aster
City/Town Journeyman License Number: •
APPROVED(OFFICE USE ONLY) ❑LP Installer