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APPLICATION FOR PERMIT TO DO GASFITTING
USE ONLY)
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Fee: $ off) - U U
PERMIT NO. G -oI
Date
Building Owner's
AT. Location v Name r 6o r�
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Type of Occupancy
New ❑ Renovation E3111 Replacement ❑
Plans Submitted Yes ❑ No ❑
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SUB-BSMT.
BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR
(PRINT OR TYPE)
Installing Company Name C. pf Zi skri / a .- A%
Address f ir-/G
Business Telephone I
Name of Licensed Plumber or Gasfitter
Check One:
ClCorp. o y - 28y6/93
❑ Partnership
❑ Firm/Company
INSURANCE COVERAGE: Check One
have a current liability Insurance policy or its substantial equivalent. Yes ❑ No ❑
If you have checked yes, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of
the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check One:
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent _
I hereby certify that all of the details and information I have submitted
(or entered) in above application are true and accurate to the best of
my knowledge and that all plumbing work and installations performed
under Permit Issued for this application will be in compliance with all
pertinent provisions of the Massachusetts State Plumbing Code and
Chapter 142 of the General Laws.
Signature of Licensed
Plumber or Gasfitter
7937
License Number
TYPE LICENSE:
0 Plumber 11 Gasfitter Faster ❑ Journeyman