HomeMy WebLinkAboutG-11-469 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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(-=_el= City/Town: /njerre0TN ,MA. Date: / 13)// Permit# `l I(46 1
Building Location: �'�/l Airwe RD ' Owners Name: J/- )S 6/TLEL-
�A matin-!Po i
G Type of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional 0 Residential• r
New:0 Alteration:0 Renovation:0 Replacement:$ Plans Submitted: Yes 0 No 0
FIXTURES
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SUB BSMT.
BASEMENT
1" FLOOR
2"u FLOOR d
3"°FLOOR
4th FLOORi
51"FLOOR 4.c05s4)'
6"FLOORF+'
7'"FLOOR - �'h
8'"FLOOR
Check One Only Certificate#
Installing Company Name: E/c�NStali , eltie-•
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C
orporation Se2cP/C
Address: pL /4LLECity/Town: L gie/nerfir/ State: 114-
set
❑Partnership
Business Tel: 6-08--397-777? Fax: SQ0- FC2S4
0 Finn/Company
Name of Licensed Plumber/Gas Fitter. .J /riONE, / /. J7///t/szew
INSURANCE COVERAGE: •
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes'No 0
If you have checked Yes,please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy X 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 ❑ Agent ❑
Signature of Owner or Owner's Agent ______,
By checking this box 0;1 hereby certify that all of the details and informal ave submitted(or en )regar•Ing this appl -. Ion are true and
accurate to the best of my Knowledge and that all plumbing work and In allations perfo ed un the rmit, ued forth .•plication will be in
compliance with all Pertinent provision of the Massachusetts State Plumb Code and hapte 42 of e Ge ral Lars.
Type of License:
By 0 Plumber
Title ❑Gas Fitter ignatu of Licensed Plumber/Gas Fitter
(1Iaster
City/Town ['Journeyman License Number: ./&a 9P
APPROVED(OFFICE USE ONLY) 0 LP Installer