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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type) q
14 maw_* f �
ee��Ch Mass. Date /� 20 /7 Permit#GI 2_ 2 3 I
7�-= t/Owner's Name 91077(5/70 S•.�
=t 11 + Building Location / �^
1I (O Vel-4f ldi/ Type of Occupancy )
-A:tw • Owner Tell/ 4-77/9 '775- —ZAPS
New 0 Renovation 0 ReplacemFIPlan Submitted: Yes ❑ No X ES _ ,
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E 1 Leii '.01 U
ope\/ EUIt DING CEM
If/ Oe 0 F et =et0 1 V o �C a n a y s
= o i i 1 1 3 c u 3 8 g c A R 1
SUB-BSMT
BASEMENT
1^FLOOR
•
2'a FLOOR '
3R0 FLOOR
4T"FLOOR
5T"FLOOR
6T"FLOOR ,
7T"FLOOR '
6T"FLOOR r f j �j
%'t't1Ins/O/ 1 �-/7 41) Check one: Certificate
Installing Company�jName �� 4e � � / ��h/ /,
Address 0 �f'-n/A'9 �I/� ft.Llorporation �i L.
S, � )1Ah Ma o;66/ ❑Partnership
lt'v' _/}'' // ^7 ..7
Business Telephone# LTA 4 '7" -7 7 /6� //J7 ❑Flr{m//Coo./)
Name of Licensed Plumber or Gas Fitter -sp/i_ef) 4 ."`�i • `�'
INSURANCE CO RAGE:
I have a cure ability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142.
Yes No 0
If you have checked yes.please Gate the type coverage by checking the appropriate box.
A liability Insurance policy Other type of indemnity 0 Bond D
OWNER'S INSURANCE WAIVER:1 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 o
• Agent o
Signature of Owner or Owner's Agent re true a d a -rate - - • sl of my
I hereby certify that all of the details and Information I have submitted(or entered)in a e application
knowledge and that all plumbing work and Installations performed under the permit issued IsLipy ation wi b in •mpl i w all
rtinent provisions of the Massachusetts State Gas Code and Chapter 142 of th9 General La
By Type•plumber of License: l\
Signature of Licensed Plumber or Gas Fitter
Title Gas fitter `02 ,Yr)
✓•Master License Number c.,
City/rows •*JourneymanAPPROVED(OFFICE USE ONLY)