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TYPE OR
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MASSACHUSETTS UNIFORM APPLICATION FOR A VtKM11 1 u YtKtVRIVI uv,o n urn+ rrvnn
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JOBSrrEADDP.ESS � 0\NNEP'SNAME ( .C.U���/
OWNERADDRESS: &I l���L�� EL' FAY /
OCCUPANCYTYPE COIAMERCIAL❑ EDUCATIONAL ❑ P.ESIDEN TIAL,I�
NEW: ❑ RENOVATIOM LJ/ P.EPLACEMENT: ❑ PLANS SURIA 11 1 ED YES ❑ NOZ/
APPLIANCES! FLOOR—
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BOILER
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BOOSitR
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CONVERSION SURNER I
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OVEN
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PDOLHEATER
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TEST
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UNIT HEATEP
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INSURANCE COVERAGE
I have a curmrY fiabT insurance policy or its substant al egWvalentvHch meets the req*emerts of MGL Ch.142 YES NO ❑
If you have checked YEAS please indicatethe type of coverag by checking the appropriate box below.
LIABILITY INSURANCE POLICY ]� OTHER TYPEINDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAVER:1 am aware that the licensee does not have the insaance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permitappGcation wa ves this requirement
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
hereby eariny that all of the details and 1rriormation 1 have subtr tiled (or entered] regarding this applicdon are true and accurate to the best of my
KnaMedge and $rat ad pbIrbing workand insWIatons perfonTad undertre pernfl issued for this app6cdcln vAll be'ur comp) noewith all P'rtr erd
provision of tre Massaohusefs State Plumbing Code and Chapter 142 of the General Laws.
PI-1.10 IGASFrrTERNAME:6& v-7OMe°S LICENSE SI ATURE
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MASTER JOUP,NEYAM1N ElLP INSTALLER ❑ CORPORATION ❑ t RE P' �c r GE�gr_z
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