GP-89 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTINGTI
DARTMOUTH, MASS. Type of Occupancy-Commercial 1-1 ResidentialL'7
Owners Name rt- S--€ enye�-e- Owners Address
Building Locat' c G SU V d,9W 1 "-at Date ��-Z V,
New [ Renovation Replacement ri Plans Submitted n
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G SUB-BSMT.
BASEMENT
1st FLOOR / /
2nd FLOOR
'NCI 3rd FLOOR
4th FLOOR
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5th FLOOR
6th FLOOR '
7th FLOOR `
8th FLOOR -
Installing Company Name Check One: Certificate
Address HANK.'S SOUTHEASTERN PROPANE
795 AmeriOn Legion Hwy Corp.
City StateWeSiport,MA Code n Partner
Business Telephone: �-`' Y 'L-c' fl Firm/Co. _
Name of Licensed Plumber or Gasfitter /ee 4e (i tJT
INSURANCE COVERAGE: Check ne:
I have a current liability insurance policy or its substantial equivalent. Yes o ❑
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;Ltd that my signature on this permit application waives this requirement.
Check One:
Owner ❑ Agent ❑
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 will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and
Chapter 142 of the GrAneial Laws.� r��
B y / // J Type of License: _ 1 ��%'�-+'c� of %t/
Signature of Licensed Plumber or Gasfitter
Title 2a 4/- ❑ MASTER
fifty/Townj/Town O `❑ JOURNEYMAN License Number !�� i S
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� °� Gas Fitting Permit
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'.1864'_Sy No.
TOWN OF DARTMOUTH /0 r • 19 93,f;
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This Certifies,that -� p �--
has permission to perform Gas Fitting for Ji-A..ef'I� ( 't,,-4[/:s a
in building C S.L-664Axe,L, /go, Street
in accordance with the Massachusetts State Fuel Gas Code.
Dartmouth Building De ment
Fee l''?
A(
?\'")771Gas Inspector