HomeMy WebLinkAboutP-11-798 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Priv or Type) / Ij �� permit II -7�� •
\iV. �j A R M 0 U tt ,Mass. Date
1� n Building L tion yµ $ CA S41 Owner's Name A-Er fl U ' IMPS
la ' �o Q j_W O n b CPN Type of Occupancy .
It. New ❑ Renovation ❑ ` Replacement 1$. ' Plans Submitted: Yes ❑ No ❑
'FIXTURES
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SUB-BSMT.
BASEMENT4 . __
1ST FLOOR II .
2ND FLOOR x jl N 1 1 i QU
3RD FLOOR . ,..---1
4TH FLOOR tun.AN a o_Pt
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5TH FLOOR er _
6TH FLOOR "
7TH FLOOR '" .. "
8TH FLOOR
, , �Jn/�// /� Deck one: -?028/
„C�ert��e�
Installing Company Name/it—yi /Mkt°0 tb .C O. Corporation O�
Address/3 i42 rcon ri re l G ❑ Partnership
• �' yC/�/nd(//1, a 0Z(c�V ❑ Firm/Co.
Business Telephone SOF/ " 394- 7776
Name of Licensed Plumber
INSURANCE COVERAGE: •
I have a curre liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yeso No❑
If you have checked yes, plea indicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage
required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application
waives this requirement.
Ch$k one:
Signature of Owner or Owner's Agent Owner I ' Age ❑
I hereby certify that all of the details and information I have submitte r entered).kt'a•ove =p•icatio• are t , and •ccurate to
the best of my knowledge and that all plumbing work and instalado erformedJode eenr the pe , 1.s i 'd fo thisG•pli altion will
be in liance with all pertinent •alli (visions of the Massachusetts State bi
By wefini" a
Title 11.0 S_ 1 G Signature of Lice sed Plumber
City/Town • D • Type of License: Master rpJourneyman ❑
APPROVED (OFFICE USE ONLY) LlcenseNumber 772%,8