HomeMy WebLinkAboutPlumbing Permit, . :
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� � , :: . , : �EP �1��� � � 2003 � ����r �o. '��-��� ���,���"
� '� �� Date 3 1 20 !�
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I A'T Loeatiort �`2 t-t Name
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{ �� ` �'Ype of Qccupancy
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Plans Submitted Yes❑ No❑
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BASEMENT � �
i ST FLOOR � ,
�� 2ND FLOOR
3RD FLOOR
(PRINT OR TYPE) � CheCk Un2:
Installing Company Name 0 Garp.
Address � C�t' ' � _
❑ Partnership
� � , ❑ Firm/Company
Business Telephone �8 ��� ��+C� / Name of Licensed Plumber � �.P�`i�d`? �r.J.��.���,.
tNSURANCE COVERAGE: !have a current liabifity insurance policy or its substantia(equivalent. Check One: Yes � No C�
If you have checked YES, please indicate the type of cnverage by checking th�ap�ropriate box.
A liability insurance policy❑ Other type of indemnity ❑ gana ❑
OWNER'S INSURANCE WANER: I am aware that the Ncensee dces not have the insurance voerage required by Chapter 142 of
the Mass. Generai Laws, and thai my slgnature on this permit application waives this res�uirement. _
Check on Ow er ❑ Agent ❑
SignatureofOwnerorOwnersAgenf ' _
I hereby certify that ai! of the details and informa#ion I haue submitted Signa re of Lieensed
(or entered) in above applicatior► are true and accurate to the be�#o# _ PEumber
my knowledge and that ail p#umbing work and instaHations pertorrned
under Permit issued far this a�pplica#ion vxi�t! be in corr►pfiance wi#h a!1 � �,,,� j�
pertinent provisions of the Massachusetts State Plumbing Code and License N mber
Chapter 142 of the Generaf Laws. �
Type: Master Journeyman C�