HomeMy WebLinkAboutP-11-789 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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Building Location 10.0 (luck.Ziit a . h( iimir 8t Owner's Name Vent? ) "—
OwnerTellt $DF—cif/— Era-- Type of Occupancy /Y9(IGt7
New 0 Renovation 0 Replacement Plan Submitted: Yes 0 No 0
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J.. 1'r FLOOR
2"D FLOOR
3RD FLOOR
Q. 4"' FLOOR
rce S"FLOOR
6TH FLOOR
7Th FLOOR
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Installing Company Name RRSTy is Mit Check one: Certificate
Address 021.2 Mrd-Talc D►y✓e $Corporation 1762 C.
We37- )ARM7nttit , MA 02473 ❑Partnership
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Name of Licensed Plumber R A-7./g W RodencK
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑
If you have checked y ,please indicate the type coverage by checking the appropriate box.
A liability insurance policy )( Other type of indemnity ❑ Bond a
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:
Owner ❑ Agent a
. Signature of Owner or Owner's Agent
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 Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /qJ /
By NJ?f& Wfideftc
Signature of Licensed Plumber
Title
Type of License:Master X Journeyman ❑
City/Town 779y
APPROVED(OFFICE USE ONLY) License Number