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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
_i. �(, Mass. Date "I la-7 ill
9 Z . tl /�
l.j Ci y, Town Permit # G' IZ ' k 109
+, J Building (� n Owner's
AT: Location . 3O 1i)ho 4' ill Name
G •
Type of Occupancy: n \dent
New ❑ Renovation Replacement
Plans Submitted Yes 0 No ❑ •
N W a F� EGEIVED
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• S O a Y u. n 3 O d a 0 a > a 0. 1— 0 -
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SUB—BSMT. , ,
v\ BASEMENT ,
1ST FLOOR N
2ND FLOOR
3RD FLOOR •
4TH FLOOR _
STH FLOOR.
6TH FLOOR
I 7TH FLOOR .
•
cr 8TH FLOOR •
(Print or Type) 1,, Q Cheer One: Certificate
Installing Company Name��1-On & 4O4 Z- 0 Corp.
Address /07 &IA d7'AJ d -deet 1 9artnership
Ve/_1710Mil
JJ9 Dalby ❑ Firm/Company
Business Telephone !- "60 -a'94`• 4 671 NaTaf liPluf T or Gasfitter
40 Utfriele arl b
I hereby certify that all of the decals and information I have submitted(or entered)in above application an true and accurate to the best of my
knowledge and that all plumbing work and installations performed under Permit issued for this application wal be in compliance with all pertinent
provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
I have informed the owner or his agent that Ido not have liability insurance including completed operations coverage.
•
• season elOwvM ere
I have a current liability insurance policy to include completed operations coverage. ❑ -
• By il 1 '• TYPE LICENSE: /dam'
/ Signa;rot Licensed
The u s 1,ze ❑ P=her Plumber or Gastitter
•
City/Town 1 • D Gasfitfer
422?APPROVED (OFFICE use ONLY) 0 Master
0 Journeyman License Number