HomeMy WebLinkAboutG-12-225 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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4F r City/Town: 7/.peo d' , MA. Date: Permk#�}1225
‘1 ''� Building Location: P n LsJiir1rer cr-t Owners Name: t dt Senrk0
G1 Type of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional 0 Residential G
i`JT,r New: 0 Alteration: 0 Renovation: 0 Replacement: Plans Submitted: Yes�L❑ No❑
FIXTURES � E "] E 1
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SUB BSMT.
BASEMENT f
1" FLOOR •
2"o FLOOR I .
3Ku FLOOR • -
4'" FLOOR
51"FLOOR 'I • '
• • 61" FLOOR - '
71"FLOOR C
81" FLOOR I . - •
Check One Only • Certificate# •
Installing Company Name: click. JrQTS� A-1A' tk jlfvJ
GLOorporation Z,253— . .
Address: 511 whilesfe.-44\ City/Town:_`bind State:/
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Business Tel:1 .- 18-690f fair 50g-?60^5 77
0 Firm/Company
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*Name of Licensed Plumber/Gas Fitter: �,h Ye rola . •
INSURANCE COVERAGE:. - _
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes7J io 0 - --
If you have checked Yes,please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy 2Other type of indemnity 0 Bond 0 '2---:
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.
Owner 0 Agent 0 •
Signature of Owner or Owner's Agent
By checking this box 0;I hereby certify that all of the details and Information I have submitted(or entered)regarding this 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 application will be in
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By Type of License: . lee
[}PtuThber
Title . . ❑Gas Fi r Si. a of Licensed Plumber/Gas Fitter
aster
Cif /Town ❑Journeyman • ense Number: /,59 y,2 •
APPROVED(OFFICE USE ONLY) 0 LP Installer