HomeMy WebLinkAboutP-12-321 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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04/7201, W-7, Date iz ' il,o ggZo/1 Permit#1:172r 1
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Owner's Name /OPTS tit/44.)
'' 6e V/4-ri✓10//y17 Type of Occupancy SPS I 52,8 79005/ 7
fE New ❑ Renovation ❑ Replacement Plans Submitted: Yes ❑ No O(.
. FIXTURES /
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SUB-BSMT.
BASEMENTa 5 � 111 F .
1ST FLOOR• rV{ 1
2ND FLOOR ' �d min. 92( 11 di
3RD FLOOR _
4TH FLOOR I BUILD NG JEW,
5TH FLOOR tt' \, .
6TH FLOOR
7TH FLOOR
8TH FLOOR
I )�pp�� Cock one: Certificate Installing Company Name .�ir�l25lOcL��t>6h` �O. Corporation Sp2�/ f
Address 8 gear Oil C'i lel'_/4. ❑ Partnership
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Z'- ycraeinelail!-) & oz(%41 ❑ Fimt/Co.
Business Telephone £n� 394- 7778
Name of Licensed Plumber
INSURANCE COVERAGE:
I have a curve liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yesf2 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.
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Chek one:
Signature of Owner or Owner's Agent Owner rd Agent •
I hereby certify that all of the details and Information I have submitt:.• or entered) in abo - :pylic: ion are true : • ,• rate to
the best of my knowledge and that all plumbing work and installations p: ••••:d uncle,t e perms Is ed fort :.•Iication will
be In compliance with all pertinent provisions of the Massachusetts State Plumbing •.r•e and C :•..r 42 of enera aws.
By
Title Signature of Licensed Plumber.-
City/Town Type of License: Master I .- Journeyman ❑
APPROVED (OFFICE USE ONLY) , License Number 7,7.24b