HomeMy WebLinkAboutP-12-010 F!
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t MASSACHUSETTS UNIFORM APPUCATION FOR PERMIT TO DO PLUMBING
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J_(— City/Town: S ygefli tat MA. Date: SA/ I,Permit#f)
Building Location:7,r I CA 1O Owners Name: �'Y,iyAfe gd/1 tC,(
PType of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential(a
New:0 Alteration:0 Renovation:❑ Replacement:t" Plans Submitted: Yes 0 No 0
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Installing Company Name:
CHECKOWAY ENTERPRISFS Check One Only Certificate#
11 SCARGO HILL ROAD 0 Corporation
Address: arch lbfS,MA 0263R state:
508-385-1911 ❑Partnership
Business Tel: Fax:
%Firm/Company
Name of Licensed Plumber. R. PETER CHECKOWAY
INSURANCE COVERAGE:
1 have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes No 0
If you have checked In,please indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy [ 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 0 Agent 0
Signature of Owner or Owners Agent
I hereby certify 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 permit Issued for this appll .tion will be In compliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By Type of License:�'/�/
Title D Plumber Signature ofilceensed rer
City/Town paster / `Y//�7
APPROVED(OFFICE USE ONLY) ❑loumeyman License Number. v )"�