HomeMy WebLinkAboutG-11-765 iZa, MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
%_' City/iown: y�WO(At ,M//�l Date: �l y j►i PermitAC�u - 7�e s�
Building Location: 3y GUI�'p I NUfrr fl.. recti Owners Name: bV1g .{ O WE0
GType of Occupancy: Commercial 0 Educational 0 industrial 0 institutional 0 Residential Ma
New:0 Alteration:0 Renovation:0 Replacement Ir. Plans Submitted: Yes 0 No 0
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SUB BSMT.
BASEMENT
1a FLOOR ' I
2M°FLOOR '
3'W FLOOR
4'"FLOOR
S'"FLOOR
8'"FLOOR
7'"FLOOR
8'"FLOOR
CHEM VAY ENTERPRISES Check OAe Only Certificate aX
Installing Company Name: 11 SCARGO HILL ROAD
DENMS,MA u2638 0 Corporate
Address: Cityntj3¢5-1911
State:
Business Tel: Fax:SDP-3k c- 6�a'$ ❑Partnership
Name of Licensed Plumber/Gas Fitter: n+Pxny
Q pFTFR CHECKOWAL.
INSURANCE COVERAGE:
I have a current(lability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142 Yes31 No❑
If you have checked YS,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 waives this requirement.
Check One Only
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
By checking this box O:I hereby certify that es of the details and Information I have submitted(or entered)regarding this application we true and
acc lance to with all best of m Knowledge and
Lire M ell plumbing work and Installations performed under the permit Issued for this eppacation will be In
nt provision of agelanelb State Plumbing Code and Chapter 142 N1 Laws.
•
BY ❑❑ of License:
•
The 110 S Pt e tr2— Wire /
Signature of licensed • !/�:doss Fitter
cayrrown (OFFICE• b.7 nakuninman License Number. A7 V/7
APPROVED U E ONL 0 LP Installer
IFINAL INSPECTION
BELOW FOR OFFICE USE ONLY PROGRESS INSPECTIONS)
FEE: S PERMIT#
APPLICATION FOR PERMIT TO DO GAS FITTING
• NAME R TYPE OF RI III OMIt•
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I()CATION OF RI M AMC - -
1 FLUMBER.GASFnER_LP INSTALLER
LICENSE NUMBER:
PERMIT GRANTED DATE - - -.
; OAS FITTING WSPECTIOR •
.