HomeMy WebLinkAboutP-08-037MASSACNUScri ['S UNIFORM APPLICATION FOR PERMiT TO DO PLUMBING
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U1 /Mass.— Date — — U P,errmit : -07-03--7
_ Building location} �l�%lf'� fi/L Owners Name �1 �t�l
Type of Occupancy.
New ❑ Renovation Replacement ❑ Plans Submitted: Yes ❑ No ❑
FIXTURES
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Installing Company Name E • F• W% N S La t J Ru Mn 3 i lug 4- Hewn a1,r Check one: Certificate
Address S Tc- A -a -yo N CI 2G 1r ) Corporation n4 - 7 44 193
So. Ya(ZM o U -1—I+ M 11- 02-1-64 p Partnership
Business Telephone (fbB) 394 — 7778 ❑ Firm/Co.
Name of Licensed Plumber E • W i N S Lc t.J =
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes 14' No ❑
If you have checked res, please indicate the type coverage by checking the appropriate box.
A liiability Insurance policy Id 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 ❑
I hereby certify that all of the details and information I have submitted (o4.entered) in above application are true and accurate to th bei allmY
knowledge and that all plumbing work and installations performed under the permit issued for this applicati and
compliance
pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
ignature of ucensea Humner
Title Type of License: Master ;• Journeyman ❑