HomeMy WebLinkAboutMiscellaneous - 93 ROCKY BROOK ROAD 4/30/2018 (30)ASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO
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.Mass. Date 19 CIF Permit #
Building Location Owner's Name TOig
Type of Occupancy
New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ N. ❑ t
Installing Company Name AUEEj_GAS -
Address-,)–11gstop St;r-egt;
TnnGfiPld MA 01981
Business
Name of Licensed 'Plumber of Gas
Check one:.
® Corporation'..
❑ Partnership
❑ Firm/Co.
Certificate
INSURANCE COVERAGE:
have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch,.;142.:
Yes? No
If you have checked Yes, please Indicate the type coverage by checking the appropriate box
A liability Insurance policy 1) 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.'b
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
knovNedge and that all plumbing work and Installations performed under the permit issued for this application will be in compliance with
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General
fay T e of License:
Plumber Signa re /b—censed lumber or Gas HtTer ,
Title Gasfitter
Master License Number
City/Town Journeyman
I1PPfi0NED ..;� f
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IMMMISIMMMMURNME
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No
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ONE
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INNEMENNUM
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Installing Company Name AUEEj_GAS -
Address-,)–11gstop St;r-egt;
TnnGfiPld MA 01981
Business
Name of Licensed 'Plumber of Gas
Check one:.
® Corporation'..
❑ Partnership
❑ Firm/Co.
Certificate
INSURANCE COVERAGE:
have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch,.;142.:
Yes? No
If you have checked Yes, please Indicate the type coverage by checking the appropriate box
A liability Insurance policy 1) 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.'b
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
knovNedge and that all plumbing work and Installations performed under the permit issued for this application will be in compliance with
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General
fay T e of License:
Plumber Signa re /b—censed lumber or Gas HtTer ,
Title Gasfitter
Master License Number
City/Town Journeyman
I1PPfi0NED ..;� f