GP-101 a�
°°Tx.M'�� Gas Fitting Permit
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TowN OF DARTMouTH JO la - 19 -9}'
This Certifies,that lattKe°v `^ .1..e
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.f has permission to perform Gas Fittingfor ,,.[//J��,B
in building /9 J ` 0"""-7 "6"t Street
in accordance with the Massachusetts State Fuel Gas Code.
Dai lmuuth Buildin Department
Fee
Gas Inspector
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
DARTMOUTH, MASS. Type of Occupancy-Commercial n Residential ❑
Owners Name ieel-4-1 Owners Address
%lII Building Location/y .5 U
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New R. Renovation U Replacement ❑ Plans Submitted n
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SUB-BSMT.
BASEMENT
1st FLOOR
2nd FLOOR
3rd FLOOR
j 4th FLOOR
5th FLOOR
2/ 6th FLOOR
7th FLOOR
8th FLOOR )
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Installing Company Name /44 24y. t' c 4(_ Check One: Certificate
Address /&/ Cail/z Sr ❑ Corp.
City S eacrt State /7 ,a Zip Code 0 ....,777 n Partner
Business Telephone: (9 76, / & 5 e-E--/ Firm/Co./
Name of Licensed Plumber or Gasfitter t/j //Os K //-r
INSURANCE COVERAGE: Check One:
I have a current liability insurance policy or its substantial equivalent. Yes ❑ No❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
a
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 ❑ 6 i
Signature of 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 knowledge and that all plumbing work and installations performed under the permit issued
for this application wil in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and
Chapter 142 of th en r ws.
B y Type of License: #29f' "�
gnature of Licensed Plumber or 6asfitter
Titl 0 MASTER a/Town El JOURNEYMAN
JOURNEYMAN License Number e9✓ 8o 3
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