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HomeMy WebLinkAboutG-12-391 ,tZ., MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING O.s drir 19 �� q �J / `__t.__:f;= City/Town: ( o 7A./` ,�eenn_ ,MA. Date: /247i/ o p/ PPermit#P t 2--3 / 1 Building Location: Z57 LVM 'L ari%�LOwnere Name: fat, a`I©' Type of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional 0 Residential' G New, Alteration:0 Renovation:0 Replacement 0 Plans Submitted: Yes 0 Not oar (O I FIXTURES - 4CW 7I' m F ig - t _ N T1 • ? of �'i a- CO V N t7 6 = CO F Q pts' a V w K f/g� a u! mQOC W0. 0.ppJ C1 O ,„_ W Zgg W a SUB BSMT. N BASEMENT N 1a' FLOOR 2744'FLOOR N 3""FLOOR 4'"FLOOR 5'"FLOOR 8'"FLOOR 7'"FLOOR „se...4 8'"FLOOR /4,At ,•s, iDa!e Check One Only Certificate# installing Company Name: aattooh Address:.3���`�i�i M wan earett Y. 4044W4;-/-t-4044W4;-/-t- State:t,/Kt' ❑Corporation /Town: Business Tel(it) gee-1i50 ❑Partnership Fax: 0 Name of Licensed Plumber/Gas FitterFIFirm/Company INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 Vas No❑ H you have checked itg,please indicate the type of coverage by checking the appropriate box below. A liability Insurance policy 6A Other type of indemnity 0 Bond 0 OWNER'S INSURANCE WAIVEER::"I am aware that the licensee does not haw the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waive,this requirement. Cheek One Only Signature of Owner or Ownees Agent Owner 0 Agent0 accurate to the By checking this box Q;I hereby certify that all of the details and Information I have submitted(or entered)regarding this application ars Due and compliance thehbest of my K ledge and that all plumbing work and installations performed under the permit Issued for this application will be In provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws, BY ;gape hunber / ///' of License: �ilni " k7 Mkt Gas Fitter lgnature of Licensed PlumberiG Fitter A Master ctynown °Joumeyman License Number. /1120) APPROVED(OFFICE USE ONLY) 0 LP Installer