HomeMy WebLinkAboutP-11-807 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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"/ARmbutl-t- , Mass. Dates Una I--( oicSi i Permit#SII - R-07
r. 't Building Location it' BR/06 F �7 y downer's Name Pp m GAR DFI A
SII' - 14. . . Vncmoe.�-t 5't'lit r; T'ypeofOccupancy ' Do 0n FT
New ❑ Renovation ❑ Replacement U Plans Submitted: Yes ❑ No
FIXTURES
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BASEMENT _ _ ' J . -R E S r tEL
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1ST FLOOR . -
2ND FLOOR Ju,i0 P 2( 11 I
3RD FLOOR, _ -
4TH FLOOR _ _ Bi ii tyr Ira r,
5TH FLOOR _ -
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Check one: Certificate
Installing Company Name Nit1 f5 AA-Vino Vino PLG4.14 b( Corporation aaa8
conic_
Address P.O • Boy 518 L] Partnership
(,>✓nie.RUi�� MP 0714,3a
U Firm/Co.
Business Telephone 508 -1181- O8'Ifp
Name of Licensed Plumber Ct-t R tS (� • BR tar.
INSURANCE COVERAGE:
I have a current liability policy or its 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 appropriate box.
A liability insurance policy 0 Other type of indemnity ❑ Bond LI
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 ❑
1 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 al plumbing work and installations performed under the permit issued for this application will
be i LccT,•Hance ' : pertinent pr.\ions of the Massachuse State Plumbing Chapter 142 of the General Laws.
TitleB
'sus S a, „tit Sig ure of Licensed Plumber .7r2 r
City/Town • 0 t Type of License: Master X Journeyman ❑
APPROVED (OFFICE USE ONLY) License Number /a40 a
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