HomeMy WebLinkAboutP-12-036 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type)
VM2ina uY-h , Mass. Date 0 7 - /g Zo i/ Permit#Rilt12-4 34
i`= t •r Building Location zVc' Camp yf StM,S Owner's Name CAcen, cite (bet
-- Il ' /1905* I/C,✓Movk-b Type of Occupancy ?rs - 57e 775/70
1EU New 0 Renovation ❑ Replacement Plans Submitted: Yes ❑ No
FIXTURES /
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SUB-BSMT.
BASEMENT -r ; -3 l` \I . r, 71
1ST FLOOR / S.
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• 2ND FLOOR r JU.. " U 2011 YJ
3RD FLOOR
4TH FLOOR CU WI,IG DEFT
5TH FLOOR u>
6TH FLOOR
7TH FLOOR
8TH FLOOR
I pp�� n/� CCk one: Certificate Installing Company� Name�,�i,�11S/OcU fa C p, lCorporation -3p2si [
Address g "Kea rc,b.n �//re./ . ❑ Partnership
• •Z)- ycr.crncy Vh /YJ& 0206 V ❑ Firrn/Co.
Business Telephone Snail 3951- 7778
Name of Licensed Plumber
INSURANCE COVERAGE:
I have a currepf liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes WI No❑
If you have checked yes, plyta 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.
• Cy&one:
Signature of Owner or Owner's Agent �) Owner Agent
I hereby certify that all of the details and information I have subm •:• or entered),_:..o : applik:lion are tru: . • accurate to
the best of my knowledge and that all plumbing work and Inst:":tions perfor••: nder I e •e -it Issued for : application will
be in`pliance with all pertinent provisions of the Massachusetts Sta : - w• g Cod: a 142 • e General La.
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By .Jair.,V f \ —.....r
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Title U ' £C. ( gnature of Licensed Plumber/
City/Town I • Type of License: Master W.- ,t 0
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APPROVED (OFFICE USE ONLY) License Number 4115