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HomeMy WebLinkAboutP-11-603 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) Pate-inelefi A , ss. pat. ©/ -�5 ell Permit#?�( -603 • 'L .9 Building Loc tion �Z L' DOIJ// Owner's Name Ed t Veti _.� -51014 in k Type of Occupancy Tio5 • -� •• New 0 Renovation ❑ Replacement ❑ Plans Submitted: Yes ❑ No Q� FIXTURES 70/- X72-l0 • op, Z y d y O Y z (= , • / Z W tzrn ►q- wrn12 ¢ to Ozzza : 'Pe? ,- ' • t. J+7 5,1 Jf/Iwro � � 2 } aLLI toY ¢ a LLdaa ,' , / 'V / UZ22waco3ix � < ZOamen NZCC 0 • :% Ott) fat f..JODof/JcT3ei> > a ~ zOpmZ � �c U OOJ2F— ALLaoEcE� OIdO SUB-BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR II //� C ck one: Certificate Installing Company NameI:A-1a 75/OcU P 6. ®"Corporation -Face/ g Address Kearth/) ('i /_ CI Partnership /Ci,-/YJU(/Sih ma. 02114 ❑ Firm/Co. Business Telephone SSS--194- 7 776 Name of Licensed Plumber INSURANCE COVERAGE: I have a curre liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yest' No If you have checked yes, plea indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of Indemnity ❑ 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 signature on this permit application waives this requirement. C rd kk 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)I above -p. ication :re true : •ccurate to the best of my knowledge and that all plumbing work and installat.-- .: orm:• •er t p��yyyy►► iss•ed forth. ••plication will be�liance with all •e hen •rovisions of the Massachusetts State Plu .�'Cod: an,. •t: 142 of t•: e.:ral Laws. a By..�tf�ll/ft,(l Mit:11 Title I .- !AL adA .nature of icensed Plumber/ City/Town Type of License: Master rd' Journeyman ❑ APPROV D (OFFICE USE ONLY) License Number i'7-;-,Z•5