HomeMy WebLinkAboutP-11-594 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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c• -,- "-_' ;r Building cation Z.-2-2- • /a A OGvnet's Name Hen Co (Z(ZI eU-i
-- At . S 8 Type of Occupancy #-r t ep ff
-cit., - New ❑ Renovatio p placement :t Plans Submitted: Yes ❑ No yk
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SUB-BSMT.
BASEMENT a . RECEIVED
1ST FLOOR
2ND FLOOR APF C 4 2011
3RD FLOOR
4TH FLOOR .7,7-777_�,]
5TH FLOOR
6TH FLOOR
7TH FLOOR
• 8TH FLOOR
II y� n Cck one: 3 Certifica e,+
Installing Company Name l`;�, ..aJ2S/D�lido.. ®"Corporation a 81
Address g gee/i'- on (2/,--(,_1(61,.. ❑ Partnership
• -Z)- )Ot-/77CILIVI) / U2(4V ❑ Firm/Co.
Business Telephone s2�£ /20a_' 395 — 7776
Name of Licensed Plumber
INSURANCE COVERAGE:
I have are liabilit No❑
No
or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes
If you have checked yes, pleaindicate the type coverage by checking the appropriate box.
A liability insurance policy vgb
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.
Ch k one:
Signature of Owner or Owner's Agent Owner Agent ■
I hereby certify that all of the details and Information I have submitt or enterad)In abov- a.•licat'.n are true. a$ accurate to
the best of my knowledge and that all plumbing work and installat ns perform under t e •:rmit'•sued fort ' pplication will
be in compliance with all pertinent provisions of the Massachusetts P ing Code al: h. •ter 142 of/General Laws.
BS woIP. ( ,Allt
Title , sz iiff Signature of icensed Plumber/
City/Town A f..J AL. Type of License: Master GY Journeyman ❑
APPROVED (OFFICE USE ONLY) License Number /47- --,h