HomeMy WebLinkAboutG-12-321 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type) �^
A� .S•gems 0 ,Mass. Date //L3 20 1 l Permit#C p� o " 3 2.1
rd sr L . Building Location 7s Worn, AP Owner's Name 'din P. Anne _ Owner Tel# 960•'306^7d7t C4
Type of Occupancy AJ/ /7TH//
New 0 Renovation 0 Replacement Plan Submitted: Yes 0 No
FIX(fURES /
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NOV 2432011Ei
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W Lu F < � 0 04
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teN t SUB-BSMT
M BASEMENT
1ST FLOOR
2ND FLOOR
_ 3ND FLOOR
-
4TH FLOOR •
• 5TH FLOOR
6.FLOOR
7TH FLOOR
6Th FLOOR
Installing Company Name /LNSTy/S ,The . Check one: Certificate
Address gf Mid—Ted1 On;/e. Corporation 174.Z C
Wer---YQMi; t.a?r--MQ -02-673 ...-----..._...__....... ..._.❑ Partnership
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Business Telephone# SOB-77S— 1303 0 Firm/Co.
Name of Licensed Plumber or Gas Fitter F>tAwK W goc11CVICx
INSURANCE COVERAGE:
I have a current liability Insurance policy or tts substantial equivalent which meets the requirements of MGL Ch.142.
YesNo ❑
If you have il<ecked y ,please Indicate the type coverage by checking the appropriate box.
A liability insurance policy S Other type of Indemnity a Bond a
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:
Owner a Agent 0
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered)in above 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 provisions of the Massachusetts State Gas Code and Chapter 142 of the Generai,L.aw�s.. J `
P t#n
By Type of License: J W /LO,r�r[�
•'Plumber Signature of Licensed Plumber or Gas Fitter
Title •C.-fitter 779
License Number
City/Town • ••rneyman
APPROVED(OFFICE USE ONLY)