HomeMy WebLinkAboutP-12-075 MASSACHUSETTS UNIFORM APPUCATION FOR PERMIT TO DO PLUMBING
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r_111 City/Town: //�2{k Ch._) 1 N ,MA. Date: .--1( t O l I 1 Permit#T(z- 0-7r
Building Location: Ctam P S t - U N k\agil
V 2 Owners Name: 9/0 I h_)
PType of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential El
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New:❑ Alteration:0 Renovation:❑ Replacement:2 Plans Submitted: Yes 0 No❑
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Check One Only Certificate#
Installing Company Name: 6c1 m +1.,,..., . -,S
0 Corporation
Address:G7otx.. Rrd�.g City/Town: t)n.. r•-1 IS State: f 'A
RH.7t�2_12-0. ID Partnership
Business Tel: 1-ta-1-SO et-coign: Firm/Company
Name of licensed Plumber: Ed (ka-I-h.e,,,s
INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 Yes"0"No 0
If you have checked nil,please Indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy ED' 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
Owner ❑ Agent 0
Signature of Owner or Owner's Agent
I hereby certifi 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 all plumbing work and Installations performed under the penult Issued for this application will be in compliance with all
Pertinent pro(vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By Type of License: r 4,..X4.-re, r TY)042.0.tom
Title Q'Plumber Signature of Licens!d/Plumber
City/Town ; IJMaster License Number: 8cs47
APPROVED(OFFICE USE ONLY) ❑Joumeyman