HomeMy WebLinkAboutG-12-036 ` Ic
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
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nR-_ `�_ / �/ /•yv//7 p1�,, Masss..` Date724 20�* Permit tt&II2--�J6
E = pF 1 Building Locatio9,VM(1/��✓ CP f"O Owner's Name S�VL4
'�= 5 Type of Occupancy 44-94-9 _
New ❑GRenovationA Replacement 0 Plans Submitted: Yes❑ No 0
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SUB—BSMT.
BASEMENT V
1ST FLOOR I
2ND FLOOR V
3RD FLOOR r
4TH FLOOR
5TH FLOOR — .
8TH FLOOR
7TH FLOOR
8TH FLOOR
Installing Company Name Seibold Plumbing & Heating„ Inc. Check one: Certificate
Address28 Carter Road XI Corporation 1810
Worcester, MA 01609 0 Partnership
Business Telephone (508) 756-6461 0 Firm/Co.
Name of Licensed 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 KI No ❑
If you have checked Is, please Indicate the type coverage by checking the appropriate box.
A liability insurance policy NI 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.
Check one:
Owner❑ Agent 0
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered)in above application are true and .• urate o the bes of my
knowledge and that all plumbing work and installations performed under the permit I:. or this ap kation will , in • pilau's '1 .II
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the •ws. • /
BY TyRe o1 license:
�.i Plumber . ' gnature of licensed umber or Gas Fitter
Title Gasfitter
Master license Number 10229
City/Town Journeyman
APPROVED(OFFICE USE ONLYI
•
A •
BELOW FOR OFFICE USE ONLY •
FINAL INSPECTION SKETCHES PROGRESS INSPECTION
FEE
NO.
�.,. APPLICATION FOR PERMIT TO DO GASFITTING
NAME& TYPE OF BUILDING
LOCATION OF BUILDING
PLUMBER OR GASFITTER
•
LIG NO.
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PERMIT GRANTED
DATE•
19_
•
GAS INSPECTOR.
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