HomeMy WebLinkAboutG-11-852 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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vj , City/Town: lh%%a MA. Date: (�/1 Permit# av
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Building Location: 42.. '��BN �O
Owners Name: „,41/4471 � � d
Type of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional
0 Residential
New•, Alteration:0 Renovation:0 Replacement: 0 Plans Submitted: Yes 0 No 0
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1 FLOOR 11111111111111111111111.11111111•1111111111111111111111111111111111111•1111110111111111111111111111111111
2 ' FLOOR 1.11.1r1.1.1111111111.1.110.111111.11.11011.1.1011.11.1111111111111.111.1.1111.1
3 ' FLOOR 111.11.111111111111111111111.11111111111111.....111111111111111111111111111111111111.111111111
4 FLOOR 111111111.1.111111.111.111.11.1.1111111111111111.11.1.1.1.1.1.1.1.1.11111110111111.
5 FLOOR 11111.11.111.11.11.1.1111111.11.1111111111111111111111111.1.11.11.111111.1111.11.1111.11.11
6 FLOOR 1111111111..-1.11.111.11.1111.1110.1.1.111.11.11111.111111111111.11.111.1.11.11.11.
7 FLOOR 1.11.11.111111e1111111111111111.1.111.11.11111111111111111.11.11.11111.1111.111.111111111111
8 FLOOR 0.111.11111.11.1.111111.11.11.1111.111.0.1111.1.111.11.11.11.111.11.11111.11.1
Installing Company Name: Check One Only Certificate#
Address: 8f1�f1t�Ju4Y ENTERPRISES CorporationState: ________—
Business Tel:_ 11 SCAR 0 Partnership
Tel:________DENNISFj& 02638
Name of Licensed Plumber/Gas Fitter: 508.385 1911 Firm/Company
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INSURANCE COVERAGE:
1 have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MOL.Ch.142 Yea f mo 0
If you have checked Yes,please indicate the type of coverage by checking the appropriate box below.
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
Massachusetts General Laws,and that my signature on this permit application wain this requirement
Check One Only
Si.nature of Owner orOtmer'sA.ant Owner ❑ Agent 0
By checking this box ■;I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and
;Aiaccurate to the best of my Knowledge and that all plumbing work and Installations performed under the pemtit issued for this application will be In
l nce with all Pertinent proWslon of the Massachusetts State Plumbing Code and Chapter 142 of 'General Laws.
‘34NIWe a` Ty of License:
By \y. • Lc'"' Q9 Plumber
True i S P A 1 Gas Fitter Signature of icense IT
Master ber/Gas Finer
City/Town t. I Joumeyman
License Number: )? )
APPROVED OFFICE E ONLY 0 LP Installer