HomeMy WebLinkAboutP-11-529 Rzocilti 8 3- 10- 1t
MASSACHUSETTS UNIFORM APPUCATION FOR PERMIT TO DO PLUMBING
=;1€i_ City/Town: of Ve"so LA
A-1"t^ )r MA. Date: I y 1 )( Permitil I I — td S-272�
BuildingLocation: J AWl aa( Owners Name:' .cI.ru. ( (t
PType of Occupancy: Commercial❑ Educational 0 Industrial❑ Institutional❑ Residential
New:❑ Alteration:0 Renovation:® Replacement:0 Plans Submitted: Yes❑ No al
FIXTURES
DEDICATED
re Z SYSTEMS
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a N �y L� a� S = r day
3 OC N W Z C$j 6 1 u , F
a33 d _ gg i il MARm 2i 1-
2 2 g a a e S S s g a g N 3 3 3 oa
SUB BSMT. r ..r ,�< .. w w
BASEMENT _
ts1 FLOOR
2Me FLOOR I
3Re FLOOR
41N FLOOR
STN FLOOR
61N FLOOR
71N FLOOR
81M FLOOR
Installing Company Name: t c L,te •V`bp l I"sti
0 Corporation
Cheek One Only Certificate*
Address: „✓ 80 5Idyl /Town: D-‘2‘414(5 State: V1/41 A.
0 Partnership
BusinessTel(CD1) 3Cs-975r Fax:
a
1.--7 (...-t Firm/Company
Name of Licensed Plumber: "R6 v\ k- 7(�.t _
INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142 Yes,®, No❑
If you have checked In,please Indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy .6 Other type of Indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waive%this requirement.
Check One Only
Owner 0 Agent 0
Signature of Owner or Owner's Agent
I hereby certify that all of the details and Information I have submitted(or entered)regarding this application are true and accurate to the best of my
Knowledge and that ail plumbing work and Installations performed under the permit Issued for this application will be in compliance with all
provb •. of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
B t._. t/ft((--•11\ Type of License: 71- � /1'qsfad A
The • :,n, 0 Plumber
Signature of'UcenPlumber
mown~ "- J 0 Muter License Number. 1 6 3( 01
APPROVED(OFFICE USE ONLY) ❑Joumeyman