HomeMy WebLinkAboutP-12-328 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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gz, 1. ArMrn.&& ,Mass. Date 41721 20 // Permit N Ps 2- 32C
,'H Building Location /50 41CC// /��tt i✓ Owner's Name Donald /f /knleYJ r _
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�ex -i Owner Tel/ cog—77/-8_33-0 ' Type of Occupancy (,irifi�f'Y�CwY
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New 0 Renovation ❑ Replacement Plan Submitted: Yes ❑ No
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FIXTURES
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SUB-BSMT
M BASEMENT
r 19r FLOOR
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2"D FLOOR
3"D FLOOR
4TM FLOOR -
I :.,..._ ._- - .. .STM FLOOR -- - - .
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�(t RTM MOOP i
installing Company Name R USil SN e s ..Check one: ' Certificate
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Address ' i :: 622.2: MDI—Tech Dh✓t t- )(Corporation 1762 C
vl/ar' )/ARMOKi1s / MA 02473 0 Partnership
Business Telephone N ,SOB—775-1303 0 Firm/Co.
Name'of Licensed Phiniber F I WK 'K Roc%ncC
INSURANCE COVERAGE: - - '-
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑ _ ._—
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If you have c ecked in,please indicate the type coverage by checking the appropriate box.
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A liability insurance policy �( .'` 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 Mass.General Laws,and that my signature on this permit application waives this requirement.
_ . _.-__._..— Check one: .
.y Owner ❑ ' "Agent 0
Signature of Owner or Owner's.Agent__ _. . -
I hereby certify that all bf the details and'information I have submitted(or:entered)in above application are trueand accutate to the best of my knowledge:
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and that all plumbing work:atxl'fastallations performed under the permit issued for this application will be in compliance lid all pertinent provision�of I �-�
the Massachusett4 State Plumbing Code and Chapter 142 of the General Laws..-- --'- - 1— ._ _,f -,- _ -
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r, By ---.. - �(pdGY1Ul. _ ........ -_ �._ �.
_._ .. Signature of Licensed Plumber . , ' !
Title _
Type of License:Master X Journeyman 0
City/Town 779y
APPROVED(OFFICE USE ONLY) License Number