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HomeMy WebLinkAboutP-11-710 N© A'pecl-vv -t, MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING �y� =;In- Cityfrown: i gr'en nu. �ir MA. Date: S�tt\tt Permit(' Til �10 s Building loeation: stC Qyck Is\cvn& Rci. ownerNam@:�ts G .is�u\n P Type of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional 0 Residential New:0 Alteration:0 p Renovation:❑ Replacement® Plans Submitted: Yes 0 No Igi Cv r ?Y n Mt:. ' G058 Y) S 1 ) 1IS FIXTURES i 2 e7Ov Y CC co z I- z m `l ct w t7 ifiejD w 4 C to Z D M q M f in QZ d m O CO ro c¢a Q Z C O ga ce 2 W ryf Z U a ly et re w a0 5 i a o a~i 3 czi Z a p 3o a JY z ai 1W- ►W- w m m o o u. a = 3 -1 g te m w 1- = 3 3 3 0 SUB BSMT. BASEMENT 15' FLOOR _ 2N° FLOOR em FLOOR 41"FLOOR-. _.. S'"FLOOR B'"FLOOR 7'"FLOOR 8'"FLOOR Installing Company Name:GE M �Ckta*\ \11C. S..rs nt s `r,c cheek One Only Certificate# gi AddressNWV.\\YsNr cies 'V. Cityfrown:t.tv,t�lh Sb`z ; 0ParnershIn 2��9 s ❑Partnership Business Tel: \ 631 ts'ice-t1 Far 0 Flrm/Comparry Name of Licensed Plumber. Fr.tE.r‘c,k VI) ox&4`M INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 Yes a) No 0 if you have checked hs,please Indicate the type of coverage by checking the appropriate box below. A liability insurance policy gj 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only . Owner 0 Agent 0 Signature of Owner or Owners Agent I hereby certify that all of the details and infonnadon I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit Issued for thb application will be In compliance with all Pe rat provision of the Massachusetts State Plumbing Coda and Chapter t42 of the General Laws. �5 4h i , \ Type of License: Title 1A?s'�sz 0 Plumber Signature of Licensed Plumber Clty/rovm !t 0 . Y 0 Master License Number. 6 ?...%APPROVED(OFFICE USE ONLY) ❑Journeyman FINAI I!\SPFG770N ' BELOw•rOROFFICEUSEONLY - FROGRI.SS INSI LCLIONal J • • . FEE.'$ PERMIT it - '' • . c ! „ APPLICATION FOR PERMIT TO DO I'LUMBINC Y _ - - r _ — .. e_. i ' a f _ tT'. y ` NAME.&TYPE OFDUIIDR(C , ti . IOCATION OF❑ II DING:. , - I ' ' ' -• SKFTCII r, •,1,� { t` rt., .. . .. I.ICENSE NUMBER' - -F 1 ` - . PERMIT GRANTED0 DAT _ • _ - _ _. PLUMBING INSPECiIOR ,�