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• MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
0 Mrcl`= City/Town: \/ Rmot. tl�- , MA. Date: 11/2/10 Permit#6 1'-✓ 15
V PoMPawo f�w) Owners Name: Mole-
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Building Location:
GType of Occupancy: Commercial 0 Educational 0 Industrial�al0 Institutional 0 Residential f�
New: 0 Alteration:0 Renovation:❑ Replacement: ✓u Plans Submitted: Yes❑ j;No❑
FIXTURES
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SUB BSMT.
BASEMENT I
1" FLOOR
214°FLOOR j
3""FLOOR
491 FLOOR sjtli .•••-•."'""-e"
5'"FLOOR _ VI 00.„^,,..+"
6'"FLOOR
7'"FLOOR
8'"FLOOR
• Check One Only Certificate#
Installing Company Name: Aqua Services Plumbing and Heating LLC.
®Corporation 3081
Address: 350 Main St. Unit A City/Town:West Yarmouth State: MA
❑Partnership
Business Tel: 774-470-1350 Fax: 774-470-1351
❑ Firm/Company
Name of Licensed Plumber/Gas Fitter:
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 ❑ Agent ❑
Signature of Owner or Owners Agent
By checking this box❑;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 all Pertinent provision of the Massachusetts State Plumbing Code and apter 142 of the General Laws.
Type of License:
By 4® Plumber
..
Title •
Gas Fitter Signature of Je nsed Plumber/Gas Fitter
®Master
CityfTown ['Journeyman License Number: 11305
APPROVED(OFFICE USE ONLY) 0 LP Insller
FINAL INSPECTION BELOW FOR OFFICE USE ONLY PROGRESS INSPECTION(SI
FEE: S PERMIT k/f!
i
APPLICATION FOR PERMIT DO GAS FITTING
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NAME&TYPE OFBU11<1)MCI
LOCATION OF BUILDING
SKETCH
PLUMBER.GAS FITTER.LP INSTALLER
LICENSE NUMBER: �i
PERMIT GRANTED❑ DATE:
GAS FITTING INSPECTIOR
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