HomeMy WebLinkAboutG-11-541 I 11 .._ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
Itt-•47 • City/fawn: /AvmousH MA Date: IIIRIIt Permk/ `
Sultana Location: 1 3 IA%1 A'n Ica S.ya>& Owners Narme "
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GType of Occupancy: Commercial 0 Educations 0 Industrkil 0 Institutional 0 Residential 0
New' ti mom 0 •Renovatart:0 Replacement 0 Plans Subrnttterk Yes 0 No
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FIXTURES
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3'm FLOOR' FLOOR
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7'FLOOR
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Installing Company Nam: ,1 r.. f 1 l f i b It / - a ,Q_,f el a Check One Only Csrtifleab P
A Po 66% ? yawn:W.Pam foe_Stat.: NA- o Corporation
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Nam of Licensed PhanbedGes Fitter l nn 112 �FhNCamparhy
INSURANCE COVERAGE:
I have a cairaM ftglaggyjhaea,noa policy w iter substantial ogulvalent whkh meets the requirements of MGL.Ch.142 The 0 No 0
If you have checked X36 plans Indicate the type of coverage by checklq the appropriate box below.
A liability Insurance policy la Other type of Indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER:I an aware that the Scene..
Massachusetts General Laws,and that my signature on this permit this the insurance by Chapter 142 of UM
requirement
Check Ons Only
SignatureOmar Owner ❑ Agent 0
fly ch
box LE I hereby that ll c teand """""I have sed(or wind)m ,..pw this applicadon we bus and •
s and ell detailsawthe Thad Ice
aappllrt.nwawlacomp�awkalPeasaaprovataatheM.�,uestSIM.p,,tting . . and Chapter 142 et ttaws. •
BY lI a License i
E b Goa Fitter a S,'nature ofLLkemehiC p Ga Fitter
Li:(OFFICE USE ONLY)
Lis.
hat, License Number. m /074S-