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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
\,.11,4.4_4-',..MINI: City/Town: licit orti- , MA. Date: Li )-(1) /P.,. Permit# G(Z'�s
Building Location: 32-1 ),0F}ITPrj PPA14 Owners Name: Li/SO 2) NIL—tra-4vL
Type of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional Residential 0
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I New: 0 Alteration: 0 Renovation: ❑ Replacement: 0 .• Plans Submitted: Yes 0 No❑
FIXTURES
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SUB BSMT.
NI BASEMENT
h 1" FLOOR
4 eu FLOOR
3N'FLOOR '
4'"FLOOR '
5'"FLOOR
61"FLOOR
7'"FLOOR
8I'l FLOOR
1J �/�� Check One Only Certificate#
14 Installing Company Name:( t'2� Pfr i71,A;k3 a
,, p 0 Corporation
nAddress:par(,/�0k a-01 City/Town:S. Nt:AJAJ.IS State f---
❑Partnership
til- Business Tel:(5-0y-)nG•277)' Fax: 11'72,U ')4(3
DPfFm/Company 230V?
Name of Licensed Plumber/Gas Fitter:k{1 CCJ rite el._e_
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INSURANCE COVERAGE: ,
I have a current Jiablllty Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142 Yes 0 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
Signature of Owner or Owner's Agent Owner 0 Agent 0
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 ail Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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Type of License: I�//�Lie/� ��::-- � ,
By 0 Plumber ,R,/L,-
Titfe ❑Gas Fitter Signature of Licensed Plumber/Gas Fitter
❑ Master
GtyRown ❑Ll tman
License Number: i/S0
APPROVED(OFFICE USE ONLY) F,LP Installer