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HomeMy WebLinkAboutG-01-503IC APPLICATION FOR PERMIT TO DO GASFITTING 1'I Tu (OFFICE USE ONL EC 19 2000 1 Il Bye Fee: $02© ~ t PERMIT NO. C— 0 12- Building AT. Location Al. ze 5 i New ❑ Plans Submitted Renovation Yes ❑ No ❑ Replacement ❑ Date 1 6d 12, 20o0 Owner's Name -&1ZK4/Fnew-L- Type of Occupancy LVELL/jl/C Cn 3 (n Y W rA rA ¢ UO ¢ Fes- N Q a J_ N W !R m ~ _ Cn cc Q 0 W XO Dp W =¢Z O y p i W=F Z W UL W~W ~ WQ Z W -1Q >- rA mO Z O SUB-BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR (PRINT OR TYPE) Installing Company Name r ✓�F 66rLe ry �LG �Tr' Address X)tlr"bw o/.jlfz.c Business Telephone Name of Licensed Plumber or Gasfitter INSURANCE COVERAGE: Check One: [3,"C'orp. ❑ Partnership ❑ Firm/Company 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: 1 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 1 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 1912 License Number TYPE LICENSE: 0 Plumber ❑ Gasfitter ICaster []journeyman