HomeMy WebLinkAboutG-12-139 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
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L /�K /�/✓/1`f/ Mass. AD V ��/"/ 20 /y Permit k �(�• —-I 34,i_ /93 L{ 41Sh //(,L� a /,
BuildingLocation Owner's Name
.. Owner TeU/ 77) 7 b � 7 Rse7 s Type of Occupancy ' 'AEI
New 0 Renovation 0 Replacement 5t< Plan Submitted: Yes 0 No J�
FIXTURESG 7
\� ,��``. N i U ops '
_ � 8 � " � 5 _P1le• A1i Li
w e w J F , = . 6 o 1 g. r2 x co cd vFi 4 3y rU:LD1N3C - — _
gr000 = E a` ouS $ 8F>> oX 15 '- --
SUB-BSMT - - - - - - ---
BASEMENT +
18T FLOOR l
2Na FLOOR
rO FLOOR ,
4TH FLOOR
5TH FLOOR ,
6TH FLOOR
7TH FLOOR
8TH FLOOR
installing company Name Efr14"//JS/UL(J Pi-/-1 (_C:� Checkckone: Certificate
Address F> 7-7/-74,&242,2,f, (1/i of/'t— / / Corporation ��, S/ CL.
�5y Iii iiA1/2 //fig_ 02.6 J1 ❑Partnership
Business Telephone# 571 ciYY�"?/ 77 j ❑Firmm/Co.
Name of Licensed Plumber or Gas Fitter v.S -e/) •/0b95,f J/Z)
INSURANCE co ERAGE:
I have a curre lability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142.
Yes No ❑
If you have checked y ,please icate the type coverage by checking the appropriate box.
A liability insurance policy 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
Mass.General Laws,and that my signature on this permit application waives this requirement.
Ch o :
• mer gent •
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered)in abo application ar true and ccu : :to the , of my
knowledge and that ell plumbing work and Installations performed under the permit issued fo appl on will b/' c• pliance y all
ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
/
By Type of License:
••Plumber Signature of Licensed Plumber or Gas Fitter
Title •Gas fitter 4 if n
.�tvtaster -- - Ucense Number �G-,f—r'ft
City/Town •Journeyman
APPROVED(OFFICE USE ONLY)