HomeMy WebLinkAboutG-12-350 - - • • ) 001i
yam\ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING ApAC.
(Print or Type) /� ��J y
__ft �A,C.MCy-At) • Mass. Date 1Z .et k‘ 19 ' Permit #Vs` 35.73
J \ nets Name �\�
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Building LocatiOrIM( %<NC\\n �Cnr)COw
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�` 1O�h \A� 7-1;� Type of Occupancy
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• New 0 Renovation ❑
Replacementpk Plans Submttted: Yes❑ No 0
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SVD—BS MT.
BASEMENT I
1ST FLOOR
•
2ND FLOOR •
3RD FLOOR .
4TH FLOOR 1 _
STH FLOOR
• 6TH FLOOR . .\ .
7TH FLOOR
SIN FLOOR /�
Installing Company� Name (GI?/ F.WL/l'///,-Tri _ Check one: Certificate •
Address -7-7 X Md/n / f Corporation
•
/) 1 7/ /14.4. ()Xi cs- 0. Partnership •
Business Telephone V99 [ -7bf ❑ Firm/co
Name of Ucensed Plumber or,Gas Fitter • • .
INSURANCE COVERAGE: •
• I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes)' No ❑
If you have.checked yes. please Indicate the type coverage by checking the appropriate box.
A liability Insurance policy93 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 Mass. General Laws, and that my signature on this permit application
waives this requirement.
Owner❑ Agent 0
ne:
Signature of Owner or Oaners Agent
•
I hereby certify that all of the details and information I have submitted(or entered)in above 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 appli��compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Ge ws. /
BY T of License: ��pp �
Plumber g6aiu a o1 Licensed 'lumber or Gas Fitter
Title Gasritter
Master License Number Ze
City/Town Joumeyman
APPROVED(OFFICE USE.ONLYI •