HomeMy WebLinkAboutG-11-527 s� c ."',11.
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
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I• {I �/ l�'t'I'-tt'IVIn.tip q�i.K.( ,Mass. DateJl'(VV 20 (l ,Permit# -Ir :.- li
Af Building Locattiioonyl� !W�Sr FW�I�t��lp/'� Owner's Name -yam
°�41:0 Owner Tet# •Nh J75• 04% • Type of Occupancy 1`'L�`J(
New a Renovation ❑ Replacement'J( Plan Submitted: Yes ❑ No
FIX?URES
P .D
a I N 0 g l aN 1 3 it
LcS1W2 'i0P0iEU 0)
1: K S O R rE0g0D38 § P0 bad tai.
SUB-BSMT
BASEMENT )C
1"FLOOR
2He FLOOR
3R0 FLOOR
41"FLOOR
STM FLOOR
6TM FLOOR
7TM FLOOR
8"FLOOR �^ / /�
Installing Company Name�EfG'9//JS/o,o ,-// (_(; Check one: Certificate /
Address 0 - &1>2 (Le eft / 9-Corporation .��cISI (s
e 5 IkaI i;14 4 'i,let 0966// ❑Partnership
Business Telephone# 57)P) --..-54)(/ "7 7 z ` ❑Firm/Co.
Name of Licensed Plumber or Gas Fitter �AE/9/5-e/) g •/�/'i 9sly,C)
INSURANCEERAGE:
I have a curre iability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142.
Ye' No ° ACCEPTED
51(
If you have checked •Les•,please icate the type coverage by checking the epproprlata box.
A liability insurance policy Other type of Indemnity ° Bond a BY:
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 :
Owner 'et*Agent °
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered)I :bove appli /ion are e -.nd an. :le to the •- of my
knowledge and that all plumbing work and installations performed under the permit issu-. •r 1.pplication , I b ••mpliance :I •
ertinent provisions of the Massachusetts State Gas Code end Chapter 142 of the General L• . -.
By Type of License: L
••Plumber ignature of Licensed Plumber or Gas Fitter 411,2-,/,Title ••Gas er ��]�y,
...Nester Number j�^
City/Town •Joumeyman
APPROVED(OFFICE USE ONLY)