HomeMy WebLinkAboutG-10-741 Oa
L - )/ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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1 •=;.r(_ Clty/rown:Y4/n�j1 On(� .MA. Date: lD-/Y�/O Permit8 Z�0 —7L//
r N Building Location:p�/// /eO f aszl/f?iei Owners Name: ,!41 () Qr6a
UCS_`0° Type of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional 0// Residential,"
ip G New:0 AReration:0 Renovatlord Replacement:0 Plans Submitted: Yes 0 No i
1r 1 s I0 FIXTURES
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SUB BSMT.
BASEMENT
hl 1" FLOOR j J
O AZ 2""FLOOR
`tl 3""FLOOR
y, 4'"FLOOR ria t)
5'"FLOOR '
8'"FLOOR
7'"FLOOR 111W
leo 8'"FLOOR
( Installing Company Name: ', Check One Ony Certificate 0
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t,J AddrsssVo2d.O�1.cel//22 city/Town:ME ?G 4o) state:/1/14 ❑Corporation; - fop:ala ❑P ershlp
Business Tel: 70 p
Fax:
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Name of Licensed Plumber/Gas Fitter. O/1-41:S
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 Yes[J No❑
H you have checked in,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 ha t the Insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this perm*application waive,this requirement
Check One Only
Signature of Owner or Owner's Agent Owner 0 Agent 0 .
By checking this box Q;I hereby certify that as of the deals and Information I have submitted(or entered)regarding this application are true and
accurate to the beet of my Knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be In
compliance with as Pertinent provision of the Massachusetts Stas Plumbing Code and Chapter 142 of the General Laws.
Li
of By ' / 9Paumseet
4Ar
Title = crUni . !tensed Plumb
e
r/Gas Fitter
cay/Town Journeyman License Number: Iifi)
APPROVED(OFFICE USE ONLY) LP Installer