HomeMy WebLinkAboutG-10-281F�
yam\ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT .TO DO GASFITTING
(Print or Type)
Mass. Date Permit
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Building Location E Owner's Name
r 11/�sT VAType of Occupancy
New ❑ Renovation Q Replacement ❑ Plans Submitted: Yes[] No ❑
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Installing Company
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Business Telephone ' '
Name of Licensed Plumber or.Gas Fitter t e F a rL6_
Check one:
L� Corporation
E3. Partnership
p Ft m/Co.
Certificate
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INSURANCE COVERAGE:
I have a curt liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑
If you haves ecked ees. please Indicate the type coverage by checking the appropriate box
A liability Insurance policy ❑ Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER:) am aware that the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass. General taws, and that my signature on this permit application waives this requirement
Check one:
Owner❑ Agent ❑
Signature of Dwner or Owner's Agent
hereby certify that all of the details and information 1 have submitted (or entered) i e I n are true and ocurate to the best o1 my
knowledge and that all plumbing work and installations performed under the perm ssued plication I b in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Ge / '
gy T of License: (\
%umber natur f censed lumber or Gas Htter
Title Maef sterLicense Number
City/Town Journeyman
k+AaVm lONLY)