HomeMy WebLinkAboutG-12-407 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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-= r- City/Town: /f3( NI:9l- S , MA. Dater 27/// PermltAG) Z- TO7
Building Location:07Z G-f 2 '<�Wao4,,
Owners Name: I414-1 l.("›.
GType of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional 0 Residential
New:0 Alteration:0 Renovation:0 Repiaceme
nbgr Plans Submitted: Yes 0 No 0
FIXTURES
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4'"FLOOR -
5'"FLOOR
8'"FLOOR
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Installing Company Name: Q ( (.. ,_,.J 'E �� Cheek One Only Certificate 11
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6014- L o 2 `
Address: FAA Al pl ro�retlon
City/Town: ��.�„� Stats: J-'
Business Tel: 5 Cr '�
C t7 p Fax: ❑Partnership
Name of Licensed Plumber/Gas Fitter. ❑Flrm/Comparty
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 Yard No❑
If you have checked Iag,please indicate the type of coverage by checking the appropriate box below.
A liability insurance poilcyCS 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 LI:I hereby certify that all of the detail*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 14 of the Oe,
BY
W of Llesnes:
L�Plumber __ g
Title,
❑Gas Fitter Signature of Licensed Plumber/Gas Fitter
❑Master 1
City/town °Journeyman License Number. /^ 3 )
APPROVED(OFFICE USE ONLY) 0 LP Installer