HomeMy WebLinkAboutP-02-208I &
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLU
(Print or Type)
Aa2i17U .Ti+ . Mass. Date (CT- Permit
Building Location 30 6 /�09Lr r C-7701 n Q— Owneea Name Ci f LLj /fi n"
c.�J %�r2h'fU�c-rN' Type of Occupancy /t �-1-0-1
New ❑ Renovation ❑ Replacement)9 Plans Submitted: Yes
FIXTURES
IING �
nce
7 No10
MENNEN
Installing Company Name R 6fa5 E ne PL6 Et NCCheck one: Certificate
Address 1 b H 77 Fr-(-m o c, rim D 19 Corporation 133 _
1-4 y ra n n! 5 i� s.s O a o ❑ Partnership
Business Telephone -7 -7 yr- 0 � I � ❑Firm/Co.
Name of Licensed. Plumber T r1 (-2) 14 e- i n o
INSURANCE COVERAGE:
1 have a current 1 blilty Insurance policy or its substantial equivalent which meets the requirements of GL Ch. 142.
Yes B' 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 appliicatio on waives this requirement.
Owner ❑ Agent ❑
Signature of Owner or Owners Agem
I hereby certify that all of the details and inform
knowledge and that all plumbing work and inst
pertinent provisions of the Massachusetts State
TM
Clty/Tow
eparxi. VOW, W7
I have submitted (or entered) in above application are true and accurate 0 the best of my
ryr�5 performed under the permit issued for this application will be in compliance with all
j51ng Cade aytd chapter W of the General Laws. i
Type of License: Master`9 Journeyman ❑
license Number m.� a 3