HomeMy WebLinkAboutG-12-306 //t-224.If % 5 / `1799
`t MASS HUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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MA. Date: ///2//// 36
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Location: SV £.I%,s a S-c LAE Owners Name: Re&.se.i.- 0£Cev.S 'wiry
GType of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional 0 Residential El-
New: ® Alteration:0 Renovation:0 Replacement: 0 Plans Submitted: Yes 0 No❑
FIXTURES
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1a' FLOOR /
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4'"FLOOR
5'"FLOOR
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7'"FLOOR
8'"FLOOR
Installing Company Name: CG,Ci/s SE/1,2C Check One Only Certificate#
Address:3�(37O ❑Corporation
City/Town: frgaticalteyer State:/g1/1-
Business Tel:Stir- 312 lye ❑Partnership
Fax:3�P-,?G 2- ace r
❑Firm/Company
Name of Licensed Plumber/Gas Fitter: Ci/2,7>f S'fiZe.s^
INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 Yes 0 No 0
if you have checked Yee,please Indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy [117 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
Signature of Owner or Owner's Agent Owner 0 Agent 0
By checking this box 1a 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
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By
Type of License: ��
Er Plumber c's ��/L
Title Gas Fitter Signature of Licensed Plumber/Gas Fitter
a Master
City/Town ❑Journeyman License Number: /O/7J--
APPROVED(OFFICE USE ONLY) 0 LP Installer .