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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
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Q?_ rl 14 , J/c n mo 14'� ,Mass. Date m2' 2C 20 // Permit#&l( — etb Z
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'f y Building Location W art-Att.' 1J i Owner's Name 4 t✓// C
°'4Z.i Owner Tel/ 2--O3 X08/— /0C3 / Type of Occupancy J j ' c
1� New 0 Renovation 0 Replacement cr / Plan Submitted: Yes 0 No fa'
"1 GFIXTURES
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CQ AIN SUB-BSMT
to BASEMENT R = C G 1/ F 11
^y ''-- 1^FLOOR I ,�
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FLOOR r MA'l ' G 2111
1' ` ' 3°FLOOR .
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\ \ 4r"FLOOR g a r-1 kir -� � r
\v]C 5."FLOOR Y' —.
1 ,\ 6TH FLOOR
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-�f�! 7r"FLOOR
hl 6"FLOOR /�
Installing Company/oName EF//U/rJsk/() pt- ) /b, Checkckone: Certificate /�
Address rY 2nEA/2 (3€Olt / Corporation 2S/ lL
c5i 3/4tfli1 h ' Ta 0264/ 0 Partnership
' Business Telephone# 5T l 091 /�77LB 0 Firm/Co.
Name of Licensed Plumber or Gas Fitter /tip//—e/) g '11.205441/0
INSURANCE COVERAGE:
I have a curre ;ability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142.
Yes No o
If you have checked yes,please irate the type coverage by checking the appropriate box.
A liability Insurance policy Other type of indemnity 0 Bond o
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 spe:
Owner Or 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 pplicatibn e true and ccu e to th st of my
kn.agokf.and that all plumbin• work and Installations performed under the permit Issued fo ap ation will b I mplianc ith all
•rovisi• s o aLl ss chusetts State Gas Code and Chapter 142 of the General Laws
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By i^I�l�%'L71:�1!:"/.-1.�p Type of License:
•-Plumber Signature of Licensed Plumber or Gas Fitter
Title 4`.4s. •Gas fitter /e.42-1q-
✓•Master License Number p[- CIG/e 7
City/Town '. S O A •-Journeyman
APPROV D(OFFICE USE ONLY)
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