HomeMy WebLinkAboutG-11-414 /Kt> aieffe Welt
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
-j City/Town: lany14t-k_ MA. Date: Ii•14-/o Perrni
Building Location: R9 pit IA,et. Owners Name: 2.6R21
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Type of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional 0. Residential Q'
New:❑ Alteration:0 Renovation:0 Replacement:® Plans Submitted: Yes 0 No❑
FIXTURES
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SUB BSMT.
BASEMENT
15`FLOOR a.
2"u FLOOR
3w FLOOR IL PILI
4'"FLOOR
ST"FLOORIt
6`"FLOOR
7'"FLOOR
8'"FLOOR
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Installing Company Name: PMcr Air.Lo,, rsd ;Ayr-% LLC, Check One Only Certificate#
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Address: Po Reif 791 City/Town: Ferts�stw(t State: Ain ❑Corporation
Business Tel: Sbt get-/7 yr Partnership
Fax: Cr%•-S crB - 37 ys
Name of Licensed Plumber/Gas Fitter: 9&u C+ rvS ❑Finn/Company
N' INSURANCE COVERAGE:
kivI have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142 Yes® No❑
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If you have checked At please Indicate the type of coverage by checking the appropriate box below.
�CI A liability Insurance policy Ej. Other type of Indemnity 0 Bond 0
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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 chocking this box❑;I hereby certify that all of the details and Infonnaeon 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 Chapter 142 of the General Laws.
BY T Pe �'
Plumberof License:
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The
0 GGsas Fitter Signature of LI erased Plumber/Gas Fitter
Cityrrown ter
❑roumeyman❑LP Installer License Number: (Z5"3;
APPROVED(OFFICE USE ONLY)
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