HomeMy WebLinkAboutG-03-871APPLICATION FOR PERMIT TO DO GASFITTING
TOWN
Building
AT. Location
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Plans Submitted
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Renovation ❑
Yes No
(OFFICE USE ONLY)
By
Fee: $
PERMIT NO.
Replacement ❑
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SUB-BSMT.
BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR
(PRINT OR TYPE) Check One:
Installing Company Name �NeA21� ❑ Corp.
Address 15� 4)1 c,%--/e ❑ Partnership
i1,Ar-1kn-5 02;L,�j v-1A �2 F1 �j Firm/Company
Business Telephone - b - Q
Name of Licensed Plumber or Gasfitter 5_�:;jvA
INSURANCE COVERAGE: Check One
I have a current liability insurance policy or its substantial equivalent. Yes If No ❑
If you have checked yes, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy 0 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
V /
I hereby certify that all of the details and infdrmation-I lta
(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.
0 w 'a �, i
Signature of Licensed
Plumber or Gasfitter
License Number
TYPE LICENSE:
❑ Plumber ❑ Gasfitter 0 Master Journeyman