HomeMy WebLinkAboutG-11-564 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
t-ral iCity/Town: /'�/W/604 , MA. Date: /•-0` // Permit#gc11 —cem
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Building Location: /7 itiaTi/4 eiOxi.S Owners Name: `tL l/iit,'n L CES,
GType of Occupancy: Commercial 0 Educational 0 Industrial ❑ Institutional 0 Residential Ir
New: ❑Alteration: 0 Renovation: 0 Replacement: 0 Plans Submitted: Yes❑ No
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SUB BSMT.
BASEMENT
1" FLOOR /
2N)FLOOR '
3N"FLOOR
4'" FLOOR
5'" FLOOR
5'" FLOOR _
7'"FLOOR
81"FLOOR '
/-
Check One Only Certificate#
Installing Company Name: Z_2n1PZ ?C4( f/UiYA" y
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0 Corporation
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Address:6�3�!/S /af]e CitylTownai Vel// State: ,Uf 9
0 Partnership
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Business Tel:577-0V -91o6i Fax: ,cuff SG o -799a FIrmlCompany
Name of Licensed Plumber/Gas Fitter: (/,` 7 4i710Oft_fJ X
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YesWNo 0
If you have checked Yes,please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy K:i 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
Owner 0 Agent 0
Signature of Owner or Owner's Agent
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
c.. pliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the neral Laws.
t ,'r IP i Type of License:
.n.ft lot. i .9l [9'�lumber Ax-1.4-
a...-7.,...07x-o-2....-","9Title 1a► ❑Gas Fitter Sicens I tuber/Gas Fitter
L�ilts�ster
City/Town /9 MAO [ ourneyman License Number: (y
APPROVED(OFACE USE ONLY) 0 LP Installer �Q
JAN 31 RECD