GP-068 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
DARTMOUTH, MASS. Type of Occupancy-Commercial ❑ Residential w
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Owners Name �GLiAt/- !�/9irG�$.Glr Owners Address / Jt�.v !3/✓5� �
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Building Lo tion /.S SdH�.H-�r� S/ Date
New Renovation ❑ Replacement U Plans Submitted ❑
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GSUB-BSMT.
BASEMENT
1st FLOOR /
2nd FLOOR
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5th FLOOR
6th FLOOR
7th FLOOR
8th FLOOR
Installing Company Name Check One: Certificate
Address HANK'S SOUTHEASTERN PROPANE lieorP
795 American Legion Hwy
City wetputn9 Code ❑ Partner
Business Telephone: 679- y3 -i, ❑ Firm/Co.
Name of Licensed Plumber or Gasfitter the C - e 0v77
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INSURANCE COVERAGE: Check ne:
I have a current liability insurance policy or its substantial equivalent. Yes
If you have checked yes,please indicate the type coverage by checking the appropriate box.
A liability insurance policy 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 D
Signature of Owner's Agent
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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 knowledge and that all plumbing work and installations performed under the permit issued
for this application wil 2. in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and
Chapter 142 of the ral Laws.
B � S Type of License: X—C('ofC//"�
4..e ,�/� ' ot PlumberGasfitter
Ti �' o//l k���/.0utoe` ❑ MASTER / �
s/Town 0, ❑ JOURNEYMAN License Number v� .�.1-7
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