P-12-009 ,.,' MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
a (Print or Type)69 �7
I len/ ,Mass. Date 7/6 20 I/ Permit#F4 /t 609
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', Building ocation � �Ne D�' lit gr- !W• Owner's Name /J7�4 � f/GI � !
._ Owner Tel# `,SVY) 65'S —plt P Type of Occupancy �pj/q!'�t,y/i(.0
New 0 Renovation 0 ReplacementK Plan Submitted: Yes 0 No 0
FIXTURES
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SUB-BSMT
4 BASEMENT I r
I\ 1"FLOOR I r Ir 1
2N0 FLOOR ,VL U 7 �O
3RD FLOOR • DIKODCp—
• :m FLOOR rix..
s 5r"FLOOR
t e FLOOR
7Th FLOOR
RrN Fr()nit
Installing Company Name RUSTY 4 SMG Check one: Certificate
Address o2aa. 141Q-Tee/ Dn✓e $Corporation. 1742 C.
EST yARMOI,¢1t ! MA 02473 0 Partnership
Business Telephone# .SOB-77c—/303 ❑Firm/Co.
• Name of Licensed Plumber FYM✓K W. 2odencE.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes $, No CI you have checked yes,please indicate the type coverage by checking the appropriate box.
A liability insurance policy 14. 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:
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 th. I plumbing work and ins ations performed under the permit issued for this application will be in compliance with all pertinent provisions of
the S bus Sta_'u 'bin: a..a and Chapter 142 of the G Laws.
artifi41►Yia'ig AK W ALVA—
' Signature of Licensed Plumber
Title L IJ .
Type of License:Master X Journeyman ❑
City/Town6 ,
APPROVED(OFFICE US ONLY) License Number 771ii