HomeMy WebLinkAboutP-11-395 , lARNOUtff
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Ptor Type), ft V Permit# Y9,3%b01r7 S.f IV�I , ass. Date'b. - : •/ Buildin Lo ation Owner's Name a 10 �P v —1211-
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=I - ; New ❑ 0 Unov tin Omit/ Replacement.j� Plans Submitted: Yes CI No IL
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II y� /� Cck one: Certificate
Installing Company Nameit/7d115/Ocl�P4- do rCorporation --302 / e
Address gearde i e/r,1� ❑ Partnership
Z- yClg-/770(//h Ina_ OZ(c�pV la Firm/Co.
Business Telephone £n f ' .39'1- 7 778
Name of Licensed Plumber
INSURANCE COVERAGE:
I have a curreptliability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes 0 No❑
If you have checked yes, plea indicate the type coverage by checking the appropriate box.
A liability insurance policy 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 subm •:d(or entero• in above 1 ation , e true and a..�:rate to
the best of my knowledge and that all plumbing work and installations .: o 'under th e • i s .d for this ap-cation will
be in compliance with all pertinent provisions of the Massachusetts State • •r .Ing Code and ' At:%142 of the •=ne .I Laws.
By L
Title Signature of Licensed Plumber
City/Town Type of License: Master Journeyman ❑
APPROVED (OFFICE USE ONLY) License Number Kg-,A-Aa