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HomeMy WebLinkAboutP-05-515OFxv fq g MATTACHEESE TOW 1�C PD rPT FEB 2 3700 s a y3o ` APPLICATION FOR PERMIT TO DO PLUMBING By Fee: $ OD I PERMIT NO. (OFFICE USE ONLY) Date —M 1 20 V Building (S(�tr, Owner's � 01,114 AT. Location ,3b/ � Name Type of Occupancy Iok /4A* , Pj-3-- New ❑ Renovation -T!; Replacement ❑ Plans Submitted Yes ❑ Nolil (PRINT OR TYPE) � �'y� �jvxfk Installing Company Name Address 2,17 / t vt 1 A v -,e, Check One: ❑ Corp. ❑ Partnership im4e.4-61IL- 696-%Z ❑ Firm/Compa Business Telephone �"d c-�s 0 0-71'3 Name of Licensed Plumber 9 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent. Check One: Yes N No ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. A liability insurance policya Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance voerage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.4$ c Check on Owner El Agent ❑:_. Signature of Owner or Owner's Agent y 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 Permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. N �-qa, Signature of Licensed j/ /Plumber Vo - License Number Type: MasterIS Journeyman ❑ z ZY Z Q W Y J to Q Q F- Z M C7 N M M vn Z(n FQ- w X= N O Z Z Z a v Z of m v=i w >' Q W Cl) z o a ca a cc o� LL W O W Q Cn C, Q W J Z Z O O J Q H a Q= N y Q Cl) Z 0 0 vi U CO) M Z c w a FW- 3 O M V= m o SUB-BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR (PRINT OR TYPE) � �'y� �jvxfk Installing Company Name Address 2,17 / t vt 1 A v -,e, Check One: ❑ Corp. ❑ Partnership im4e.4-61IL- 696-%Z ❑ Firm/Compa Business Telephone �"d c-�s 0 0-71'3 Name of Licensed Plumber 9 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent. Check One: Yes N No ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. A liability insurance policya Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance voerage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.4$ c Check on Owner El Agent ❑:_. Signature of Owner or Owner's Agent y 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 Permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. N �-qa, Signature of Licensed j/ /Plumber Vo - License Number Type: MasterIS Journeyman ❑