HomeMy WebLinkAboutP-12-224 Unit 503 ,' MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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P`-_-y W y4t ,Mass. Date 1/72--2— 20 11 Permit q3,j — ai .3
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:-. -114._--=-- Building Location 3Ns Cy ;I-- Owner's Name CIA WAtd .4170 /cite.
Vtjl Owner Tell 0/7-PO-/7,✓'J - Type of Occupancy 11/1ldtil- n{'
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New 0 Renovation 0 Replacement �C Plan Submitted: Yes 0 No 14
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SUB-BSMT
BASEMENT I _
%.9 1n FLOOR I-, €- r Prin.' r
2"o FLOOR ; I _ - -'-
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4"FLOOR FLOOR Ii NOV d �'
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"r 5Th FLOOR 7 -J
` - 6TH FLOOR -- -
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Installing Company Name R tf STY s Z c Check one: Certificate
Address a2 Mid-Tru( Dnit %Corporation 1742 C.
p✓4f yi}RA1Gtcrit , MA 02473 0 Partnership
Business Telephone# .SOB-775—/303 ❑Firm/Co. _
Name of Licensed Plumber Fp-Mg v✓. Roderick.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
YesNo ❑
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If you havechecked ym,please indicate the type coverage by checking the appropriate box.
A liability insurance policy ;I( 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 Mass.
General Laws,and that my signattue on this permit application waives this requirement.
• Check one:
Owner 0 Agent 0
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of
the Massachusetts State Plumbin Code and Chapter 142 of the General Laws.�
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Signature of Licensed Plumber '
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Type of License:Master X Journeyman 0
City/Town .'7 0 -
APPROVED(OFFICE USE ONLY) License Number II Li