HomeMy WebLinkAboutG-11-279 - - MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
E:W50--a- City/Towngi , MA. Date: 101-6-76 Pe mit# [i('Zrci
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Building Location: /74 &1] S7 Owners Nam / - /
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GType of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional 0 Residential
New:0 Alteration: 0 Renovation: ❑ Replacement:12/Plans Submitted: Yes❑ No[r
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FIXTURES
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1" FLOOR _
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7'" FLOOR
8'"FLOOR _
Check One Only Certificate#
Installing Company Name: E. F, lA✓/NSLDW, INC ,,����,,rr
�ARDD� ( Corporation l�o�
Address: //eUFCity/Town: �]�7. 4/e/Y1007721 State: MA
❑Partnership
Business Tel: S08"39V-7778 Fax: Ste-S9V- Rare,
❑Firm/Company _
Name of Licensed Plumber/Gas Fitter: E. F WL/VSL,O&J
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YesNo 0
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❑;I hereby certify that all of the details and Information I ha - bmitted(or entered)regarding is application are true and
accurate to the best of my Knowledge and that all plumbing work and Installati• s pe +• • -- under the permit issui or this application will be in
compliance with all Pertinent provision of the Massachusetts State Plumbing ••de a i C a• er 14 of the C per laws.
Type of License: s / // iJ
By ❑Plumber _
Title
0 Gas Fitter Signat of Licensed Plumber/Gas Fitter
0 Master
City/Town ❑Journeyman License Number: "7939
APPROVED(OFFICE USE ONLY) 0 LP Installer