P-11-817 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type)
t k2MOterk' , Mass. Dateath IC 21 10 t Permit#Itl I ,17
E •r Building Location241O%MS Owner's Name -FRAM k-STt�
+a • ', uN Com'M(Q VJ.I P-Mai w Type of Occupancy_FeS I
( New ❑ _. ., Renovation ❑ g Replacement. Plans Submitted: ' Yes ❑ ` No ❑
FIXTURES
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1ST FLOOR ><1. _
2ND FLOOR ( 1U 1 ° L 2 )11 •
3RD FLOOR S
4TH FLOOR BL ILD NG JEFT.
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5TH FLOOR �.—
6TH FLOOR
7TH FLOOR _ _ _.. _. _ . _ .
8TH FLOOR _ .. __ •
gDock one: Certifica e
Installing Company Name.et/rtal?4/OcUO Pig–C O. poration --3' cf C
Address g 'ea P2*/i ei rt_/� ❑ Partnership
Z- YC/LtncJYWO') 1790 OZWO 41 ❑ Firm/Co.
Business Telephone SnE5 - S 94- 7776
Name of Licensed Plumber
INSURANCE COVERAGE: "
I have a currepf liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes0 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 submitt r enteral)in ab• : :police'•n are true • accurate to
the best of my knowledge and that all plumbing work and Installa ons performed und: the •ermi ssued fort. ppiication will
be Allis.fiance wiiI all I_rtinent provisions of the Massachusetts Plu Ing Code - • h pter 142 of . eneral Laws. •
Title tU al i Signature of Licensed Plumber
City/Town T fl • Type of License: Master Journeyman ❑
APPROVED (OFFICE E ONLY) License Number 7,7ne