HomeMy WebLinkAboutP-11-799 I I
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type) •
yoy-nn iSeV1 , Mass. Date to
to " l 3 sO CI Permit#
z _ ! .'Type. Name I D RI
E. �i •9 Building Location 6f3 PaactVIIfi W,4 Owner's
--..me '= • J• `farnAO• le T e. ofOccupancy " 1 ESI 'I�NCE
New ❑ Renovation U Replacement,' -- ; Plans Submitted:-; Yes .0' • No ❑
Z y
CO yOzf•�, am
COL 03 MI
> 0 cc
co rc
-
Ozm Fwc cZ ' rnd ' 0 U.1 al
ZEa2
0 z ¢ w cc
2 I- CO z o ga� o a cc a o O L
W1 Ire tx = � 0C2 a0l— c a � a. ;4 Lij
;i ¢
I _nQ 11 S c ec d 2 CO CO K cc O e[ O 9 d f E cc O d I
3 %1 YJrornOo � shrni'Llamcicc ccm0
�Q/ SUB-BSMT.
•
t 110 BASEMENT , .?< , , , p
Joe 1ST FLOOR " ',
2ND FLOOR -
3RD FLOOR Aiv i u dii
4TH FLOOR
5TH FLOOREJILDiNt. Lit'a.
6TH FLOOR
'
7TH FLOOR
8TH FLOOR - . . ._ .. • - -. - -
�� / �//}�/' do C ck one: Certificate�+
Installing Company Name f A t ll5/D4L// t4' . tCorporation -3,2Li ["
Address 8 K&?retie) ei re_14 ❑ Partnership
• ‘?- Y e/g•,/7-7 Oa WO CYJex. OZ(4V ❑ Firm/Co.
Business Telephone Sniff - S9el- 777
46
Name of Licensed Plumber
INSURANCE COVERAGE:
I have a currepi liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
YesIZI 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 2, k one*
Signature of Owner or Owner's Agent wn: ' i-nt A
I hereby certify that all of the details and Information I have submitted or entered) in a ve applicati.. :r•irue : • :ccurate to
the best of my knowledge and that all plumbing work and Installations erformed and the permit .2.%e• for thi ,.plication will
be in •. , lance with all ertinent provisions of the Massachusetts State bing d and Ch•a l '2 o th: t : . :ws. •
IP
By r +L'at'►�AA!1��r1
Title - . ' M.1R Signature of Licensed Plumber/
City/Town War Type of License: Master Pt.- 1 CI
APPROVED (OFFICE USE ONLY) License Number /,�j�tb