GP-6826 I . ...—
r MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTIN
DARTMOUTH, MASS. Type of Occupancy-Commercial ❑ Residential 61
Owners Name e a K-«r Owners Address
Building Loon c%' ,6 S(Ij 'ckci" /1 Date AC'/(' ,f
New 111 ' Renovation n Replacement ❑ Plans Submitted ❑
cn
rr�
z o
cn
a a o x H
tx z H
1 * L z 0 w ¢ x z 0 z • O
-_ ww ¢ W w � � arx > � w
vg p; z U �1 x v) W tx Q F., r2"
-_1 ww � � � ¢ xxx w w xtx
U �
- — C7 H z a H z w w � O � w H W L.Li
w�.,, _� z ¢ WW ¢ �4 � F" � rnpa Oz � O � x
J Z x 0 '1 x w 3 A v9 a OU ct Q a v O
SU B-BSMT.
G BASEMENT
1st FLOOR J '
2nd FLOOR
-.?"' 3rd FLOOR
' Ai ./ ,_./:7 4th FLOOR
5th FLOOR
i, 6th FLOOR
/ 7th FLOOR
8th FLOOR
Installing Company Na Check ne: Certificate
Address 793itiEviERI cad L GEoN HWY. Corp.
WHOM MA 02790
City State Zip Code ❑ Partner
Business Telephone: CO&'625'f! C) I I Firm/Co.
Name of Licensed Plumber or Gasfitter Dehae,r_s
INSURANCE COVERAGE: Check e:
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 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 ❑
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 to Plumbing Code and
Chapter 142 of the General Laws.
B y Type of License: i '�//�2 V•
Si nature of Li ens urn er or Gasfitter
Title ❑ MASTER
City/Town O T /EYMAN License Number LP Z�r
r�
z
w '
z r-- .
w' W j
O
rA
0 g. - k a
g , Li
z
: 1 d E• r.) w
E. rx
A & ' :,..,
A A \9 O A z Lw C7
A z L W w ,�� z a F ,
p 5 Ua 'o x A
F pa E
l A ao \W a
I51, '
W
x
WU
d
v) C
1
L
=�'` A CON TH OF MA.SSACHUSETTS
R
M:ENT OF INDUSTRIAL ACC'm S
-- 6)0 WASHINGTON STREET
Caramel:
---•ssione• BQ :ON, MASSACHUS ETIS 02111
WC ;' CO EPENSATION INSURANCE AFFIDAVIT
— / 1\-./ .____.S. i j
li nscc/perrttittec) ' � CJfr/v �J ��C
:n a principal place of bus
� .... IBC • S ) 7 -7 ;J 2
h,
lcreby certify, under the (C(City/State/Zip)pa; �cnalti s of perjury. that:/
I am an employer providing !owir;r, workers' compensation coverage fo
r or my employees working on this
' ____O_____LL__. A _____.,V
:ranee Company V3----
Policy Number
I am a sole prop.Icroz and l-
re ti,, ,:-king forme.
I
am a sole proprietor, gene. 2 or or homeowner (circle one) and have hind the contractors
have the following workers rs listed below
.isat.�., insurance policies:
of Contracror -
In cc Company/Poliey Number
of Contractor
Insurance Company/I'oliry Number
= of Contractor —_
Insurance Company/Policy Number
am a homeowner performir. wort: :nyself.
NOTE: Please be aware that
tg ofN not more thin three `:,ow:. :, who employ persons to do
units nor::;_ow-owner also raidea or on the maintenance, t n t t thereto
or rrpair work on a
:rednerally
to be craploycrs t.>_:der the ' - grounds apptsrttnant thereto are not ar may -.,r=, i:Sznon Act(GL C. 152,sect. 1(5)), application by a botneow�ner for license
evidence the leg-al cure ?Iovrr '..adcr the Workers'
Compensation Act.
stand u
that a copy of this stcrtrc - -
:ion i d that failure to sec;; 'orwar ed ro the Department of Indtssrrial Accidents' Office of Insurance for mveragc
rc cc .:1rc;. .:ndcr Section 25A of MGL 152
ng of a Fine of up to S)SUO.OU a: can lead CO the imposition of ciminal penal ues
i 1 00.00 a day „ t of up to one year and dvil penalties me form of a Stop Work Order and a
agaito ^c.
7-7
this
- day of 19
-c/Pcrmirrcc -
Liccnsor/Pcrmicior