HomeMy WebLinkAboutBuilding Permit # 2/2/1994 MASSACHUSETTS UNIFORM APPL CATIC� FOR PERMIT TO DO GASFITTING
(Print or Type) '
�? Mass. Date �. 1 " Permit #
Building Location IV Aa ,,1 ` Owner's Name a r 0
Type of Occupancy
New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No ❑
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SUB—BSMT.
BASEMENT
IST FLOOR I
2ND FLOOR
3RD FLOOR
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4TH FLOOR I
5TH FLOOR '
6TH FLOOR
7TH FLOOR
8TH FLOOR
Installing Company Name � Check one: Certificate
Address _ ❑ Corporation
11114, ❑ Partnership
Business Telephone ,✓ a" 1 16— ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes El No
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy ❑ Other type of indemnity O Bond C
OWNER'S INSURANCE WAIVER: I.am aware that the licensee does not have the insurance coverage required by
Chapter 14 of t e Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
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-1__ ' Owner, Agent O
Sig ature of ner o Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered)in above plication are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the permit iss r this application will be in compliance with all
P P Plu be p the G caf'Laws.
g�rtment provisions o the Massachusetts State Gas��ef-ticense:de and a ter 142 of � A Y
m t --Signature of Licensed Plumber o as Ftte(
Title G er �..-
�aster License Number Af e..
City/Town Journeyman
APPROVED OFFICE USE ONLYI