HomeMy WebLinkAboutP-11-616 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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S. Y A R N\O O Tt( ,Mass. Date 4 . g - s Permit#If f 1-6f
I� • ' n; . it, Building Location (' 9 AS TO IIC-a 1P'/ Owners Name N\O RA S S /
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�_ : - . ,.type of Occupancy
i� p New Renovation ❑ Replacements, -- PlansSubmitted: -'Yes ❑ No O
._ .,= FIXTURES ...,. . _ . . '.. '
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SUB-BSMT. - ` .
BASEMENT
1ST FLOOR `— '—(�^
2ND FLOOR I :11 I? 1' ! II l (; (II'
3RD FLOOR ( -\A
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4TH FLOOR - I ill - Of; -1 3 iu I
5TH FLOOR z '
6TH FLOOR
7TH FLOOR _
STH FLOOR -
�^ / nuub� check
orpo one: 3„Cert€ca)e t
Installing Company Name�;�i.a11 S OcU� t�5"eO. /Corporation D� / (-
Address 8 geC1 robin ('i ril 1& 0 Partnership
• •SI- )cie-n O/A/P) l� Uz(c� � ❑ Firm/Co.
Business Telephone .TJe- 394- 7778
Name of Licensed Plumber
INSURANCE COVERAGE:
I have a curreptliability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes Id No❑
If you have checked yes, plea 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 application
waives this requirement.
C ; k one:
Signature of Owner or Owner's Agent • , er 't A•. , U
I hereby certify that all of the details and Information I have bmitted(or e Ared)in abov: :.•r ation are : and accurate to
the best of my knowledge and that all plumbing work and installa i• •:,,• ed under t•�•: it'-sued •- h' application will
be In compliance with rralll�l pertinentppAA��provisions of the Massachusetts St. •''I mbing Co.: :•• e h.• er 14 •f e General Laws.
BTitle c MO4 Signature of Licensed Plumber/
City/Town ..t. 0. / Type of License: Master .1 Journeyman ❑
APPROVED (OFFICE USE ONLY) License Number //-7-11t5