HomeMy WebLinkAboutP-12-2316 • MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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-.96.------- -1,.. .l S`Ol .Mass. Datelo�(3J 20 ( ( Permit ll .PI i__- 31 6,
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- Building Location 3 C a' !. , • Owner's Name ej Utz oy,
-1I17/..• o Owner TeU/ 56—?Act_5191 Type of Occupancy 120S
�� New 0 Renovation ❑ Replacement p Plan Submitted: Yes 0 No 0
FIXTURES
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p , m BASEMENT - -
1'T FLOOR •
mT ? FLOOR '
3F0 FLOOR • . •
... 4T"FLOOR • ..
51"FLOOR : .• ..
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6"FLOOR '
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•',Installing Company Name S110/43 14.1;1 ifGer l9 : Check one: Certificate
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• .Address S W�Iiey (�rtI n— poration ;0255
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5,"jrrwi /114 _(p(,c,(•,{ 0 Partnership
• Business Telephone N t9-(S4O k c_6(-14 t/-360"5-017-2 0 Firm/Co. •
Name of Licensed Plumber inti)(fiCCi •
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' INSURANCE COVERAGE: •
I have i Current liability insurance policy or us substantial equivalent which meets the requirements of MGL Ch. 142. •
Yes No ❑
If you have checked yes,please indicate/ the type coverage by checking the approprine box.
A liability insurance policy LY Other type of indemnity 0 Bond 0
- -O W?4ER"S-tNSt1RANCE-WA1VERT-1-am-aware rthrficensee-dres.nat-have the insurance coverage required by Chapter 142 of the Mass.
General Laws.and that my signature on this permii application waives this requirement.
Check one:
• 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)in above application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued far 'S;tpp' tion will be in compliance with all pertinent provisions of
the Massachusetts State Plumhine Code and Chapter 1.42 of the Gene
By .
• Signator .n'tcensed Plumber
Title
• ?; •. • r- f License: Master t)/ Journeyman ❑
°r"s- City/Town IS?y2—
"•i4r'"• "APPROVED(OFFICE USE-ONLY) License Number L
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