HomeMy WebLinkAboutG-15-036 SA MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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OCCUPANCY TYPE COMMERCIAL El ]
EDUCATIONAL RESIDENTIAL
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES El NOD
APPLIANCES 7 FLOORS-' BSM 1 2 3 4 5 6 1 8 9 10 11 12 13 14
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11 [ _r�mmai INSURANCE COVERAGE
I hive a ctmefiit ability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES '< NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ 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 AGENT
I hereby certify that all of the details and • anon I have submitted or entered regarding this application are bye 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 lancewith ti r6 provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4.....—....._
PLUMBER-GASFITTER NAME ROUE p ffAC•Y/e I LICENSE# W!I I IGNATURE
MP 0 MGF❑ JP 0 JGF❑ LPG!❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME:N kith fg/iOrstel /friN4 I ADDRESS 602 ltI.0 RA.<TPV i?D. I
CITY ,fK/A//S STATE rjmmZIP (10/4 31? TELI.COR— 3?S-9ICS- I
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