HomeMy WebLinkAboutP-12-125 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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�. `� R mouiH , Mass. Date �F� , 0011 Permit#112- 25
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Owner's Name tCaehF_L A-
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11 n 1-7— I `i S.V ACWI Type of Occupancy_erns1n LirnT
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New U Renovation U FIeplacement XTURES
>( Plans Submitted: Yes ❑ Nog
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BASEMENT
m 1ST FLOOR
2ND FLOOR _ •
3RD FLOOR _ " '
4TH FLOOR _
5TH FLOOR . .
6TH FLOOR . - . _
7TH FLOOR _ _ _ _ .
8TH FLOOR - - Check one: Certificate
Installing Company Name I Jan c5 A. 14E tno PLc6-NC 1' Corporation ;;a3 g
Cor.. lc_ U Partnership
Address P.O . Bose 5T8
(,em i e_Ru it../-E- mR OaC'3a LI Firm/Co.
Business Telephone 5OS 11W OC1tp
Name of Licensed Plumber Ct4R LS G • SJR ted.,
INSURANCE COVERAGE: •
I have a current liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy U Other type of indemnity U Bond U
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:
Signature of Owner or Owner's Agent
Owner U Agent U
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 for this application will
be in compliance with all pertinent provisions of the Massachusee State Plumbing Chapter 142 of the General Laws.
By �t iy-C/ Chapter
Title Sig ufe of Licensed Plumber
City/Town Type of License: Master K Journeyman U
APPROVED (OFFICE USE ONLY) License Number /d90 I
BELOW FOR OFFICE USE ONLY
FINAL INSPECTIONS SKETCHES FEE PROGRESS INSPECTIONS
NO.
•
APPLICATION FOR PERMIT TO DO PLUMBING
NAME &TYPE OF BUILDING -
LOCATION&TYPE OF BUILDING
PLUMBER
PERMIT GRANTED
DATE 19
PLUMBING INSPECTOR