HomeMy WebLinkAboutP-12-270 VV ) i
t ihi ACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
'- Ct own: ///504:�/ // �/ fl 70
�A �J-ic ty/TMA. ate: / Permit# 2-�
Building Location: Se ear 5 Owners Name:P 7 &.1e-n1✓Q-
PType of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional 0 Residentiai
New:0 Alteration:0 Renovation:❑ Replacement 0 Plans Submitted: Yes 0 No 0
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1TT FLOOR
2"a FLOOR
3"a FLOOR
4T"FLOOR
5T"FLOOR
C'FLOOR
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sTM FLOOR q744-449
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Installing Company Name: 8744-4 �t 9 t$ -4--/4-12-... Check One Only Certificate#
9 // // f /q G 5 / Corporation
Address:-3 ecJ�tr7'GS cityfrown; .11/L�C State:/H� �
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[Partner L5 e R. 5ni" — 7Business Tel: -57091.13-51/147 Fax: SOS— 710,,167.0 ❑Firm/C ny i I
Name of licensed Plumber. j{a ! q rs4 her NO I.)
INSURANCE COVERAGE: RV 90/
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I have a current liability insurance policy or Its substantial equivalent which meets the requirem et et -Yes No❑
If you have checked ige,please indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy ❑ 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
Signature of Owner or Owners Agent Owner 0 Agent ❑
I hereby certify that all of the details and Information I have submitted(or entered)regarding this application are true and accurate to the best of my
Knowledge and that an plumbing work and Installations performed under the permit Issued for this application win be In compliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the Ge • Laws.
By Type of License: Ar- ��—Tkie ❑Plumber Sign.t Licensed Plumber
CmRown 0 Master License Number. 1/42/
APPROVED(OFFICE USE ONLY) ❑.1011meyman