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• MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
FI City/Town: /', // J , MA. Date: Al Permit#�I —�(�
1-.4=.. ,
ett"• Building Location: e213 WAtimatti ga, Owners Name: Fthad J '
Type of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional 0 Residential ,_G New: 0 Alteration: 0 Renovation: 0 Replacement: ❑ .— Plans Submitted: Yes 0 No 0
FIXTURES
eC r F- tri RECEIVE
COto Ii CO
l= ¢• z } w Z coX re 0 w MAY 0 6 2011
O Z (rr O I— tL O 4 F-
• ti 3 ina a-
> to z cn Lu a) OF W N p 4 W 2 •LL 3UILDING DEP".
tu •
W K `-' I Q Q Om W O 2 'O FN- '= W W 111 W BY— _
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Vo 0 OO u=„ 0 f2� 2 2 o a x re I-- 7 7 > O ,
SUB BSMT. .
BASEMENT t , _ . I •• .
1" FLOOR . •
• 2NO FLOOR• • •
3H' FLOOR 1 : . - •
• 4'"FLOOR , ' •
5'" FLOOR
• . 6'"FLOOR •
71"FLOOR '
.8'"FLOOR
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��"" �,, /�� Check One Only . Certificate# •
Installing Company Namer tith,4n fi_ � az`� .�
P�y"�� '/..^,J �/ J CorporationL
Address:JC &Meg e^"'1 CityfTown: 7A ` State:MR c
OD•blot( 0 Partnership
Business Tel:„c1-3-3q9-Equi Fax: �(a0_ 1 l
,,_t �,, •
❑Firm/Company .
-- - Name of Licensed Plumber/Gas Fitter: COStln Ve/ f€SCG- ——
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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 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.
• Owner 0 Agent 0 •
Signature of Owner or Owner's Agent '
By checking this box LJ;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
�Sall rtinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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BY \ I i C. t.r _- .At Typ Icense: 1 /,/
lumber / .
.Title 1 u 'r ❑Gds Fitter Sig - .• ie of Licensed Plumber/Gas Fitter
aster
City/Town • v.•e" ❑.lourneyman cense Number: IJ /yc. .
(OFFICE OFFICE U ONLY) Li Installer ,