HomeMy WebLinkAboutP-11-513 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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._ y/is --I" MA. Date: FSS 27 70// Permit#'1
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Building Location: 9 5' eAPTMa CAnt /fa° Owners Name: STu,.e '&<J€s
PType of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential L
New:❑ Alteration:0 Renovation:❑ Replacement:Er Plans Submitted: Yes❑ No❑
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1ST FLOOR I ) I I
2N0 FLOOR
3ae FLOOR
4T"FLOOR
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6TH FLOOR
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installing Company Name: a f-W Sen.)1 CL Co.,n-., Check One Only Certificate#
0 Corporation
Addressd&r51.64TWt)rCn+u City/Town: a c.c&%c.L. State: °Al-
or r- 0 Partnership
Business Tel: .Sot `/3o 135z_ Fax: S-dt 5/3a 723-3 0 Finn/Company
Name of Licensed Plumber: ttl/LG fnvn aserf '
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yeses No❑
if you have checked Yes,please indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy El Other type of Indemnity 0 Bond ❑
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 ❑
Signature of Owner or Owner's 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 application will be In compliance with all
t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By ti, :A•let.. I • '• Type of License: L7.C%/
me I/t�.si TI:.
_ 0 Plumber
Cirylrown � . (aster
APPROV (OFFICE USE ONLY) ❑Journeyman License Number: 2O7/