HomeMy WebLinkAboutP-12-088 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
i (Pri t or Type) /JNA
Alemd y " `.ass. Date -% 10 1g?c// Permit#?12 -OB'r
,t, 1J Buildinn Li. ocation /S Se Owner's Name-' a�'8nha+� _ %�ann'e—
�? --oS 'IC9 rrnertl it / i Type of Occupancyt r0s 'J
tE, New-0 Renovation ❑ - --. Replacement r - '--;Plans Submitted:,-Yes ❑ ' No.tar/
-_,- FIXTURES
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SUB-BSMT.
BASEMENT f - •
1ST FLOOR
• 2ND FLOOR
3RD FLOOR
4TH FLOOR
5TH FLOOR - - _
6TH FLOOR
. . . 7TH FLOOR . -
8TH FLOOR
Cteck one: Certifi e
Installing Company Name ;f;GaJ2S�OcU�f> �p. IB�Corporatlon -3 2 t�
Address 6 /?ev rc/D/1 (1/2-7!../&_. ❑ Partnership
• ' - ycrgine/UM CYJa. OZ(kV ❑ Firm/Co.
Business Telephone STJT- 394- 7778
Name of Licensed Plumber
INSURANCE COVERAGE:
I have a
Yes�liabilit Npool❑icy or its substantial equivalent which meets the requirements of MGL Ch. 142.-
If you have checked yes, plea indicate the type coverage by checking the appropriate box.
A liability insurance policy V 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 submi (or entered)In abo a applica on are : .nd accurate to
the best of my knowledge and that all plumbing work and installati s performed nder th perms ssued • is application will
be in compliance with all pertinent provisions of the Massachusetts Sta umbi Code a • ' h- •ter 14 • the General Laws.
By
Title Signature of Licensed Plumber
City/Town Type of License: Master Pt' Journeyman ❑
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APPROVED (OFFICE USE ONLY) License Number -A,ph