HomeMy WebLinkAboutBLDP-11-577 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
_
5 -'�` -/ Cityirown:
X9,6722,077/ MA. Date: /ay/// PermiHf��' 577
Building Location: ID 4JP1:J07� ROP a Owners Name: Ain, davv,
Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential%
New:❑ Alteration:❑ Renovation:X_ Replacement:❑ Plans Submitted: Yes❑ No n
FIXTURES
103 DEDICATED
tx
SYSTEMS
CNC w
rt.,
z
W m2 .. Zy, Li 7
N N a N} J V N N
r„ 0 z z °z et
Z 3 N = N a W N H W 7- N N Q F F Cd a
S3 K K X
kc 0 7 Q N Q a W CC Q gg W Z W J Z 1J L ,y T. a
a Y E. = G 0 3 2 Z Q W 3 w. x a W W W oa O W W
a m m c o °x x 5 5 °c = la- F. 3 3 3 o c u w w 3
a 0 0 LI 3
SUB BSMT.
BASEMENT -
— --in FLOOR I - —RECFL r—, - —
2NFLOOR
3"D FLOOR — - I
41"FLOOR NAN TB 2311
5T"FLOOR _
6T"FLOOR '" _
7T"FLOOR RIP Fri,. 3 N aT
8TH FLOOR _/..--a--—
Check One Only Certificate#
Installing Company Name: . r,/Ch/r/jJ/3/4/QJ //Ve,.
p ,G � ,'`em&7/ Xt:orporation 3a Pi �+
Address:Q �GA/f?/�O/�Lle• CRy/Town: (J' Stater 4—
�7 b /1,/ (� / ❑Partnership
Business TelL� 39s-7T/O Fax: 502-37Y-Oo�.c(�
0 Finn/Company
Name of Licensed Plumber: ..."7-4-,0,9E-A/ 4. A/,,ysLad
INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 Yes/0 No 0
If you have checked Yes,please indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy y 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 I
Signature of Owner or Owners Agent
I hereby certify that all of the details and Information I have submitted(or enter , regarding is appl' i,n are true and accurate to the best of my
Knowledge and that all plumbing work and Installations performed under the • milt issu • this pli.-tion will b- n compliance with all
Pertinent provisi of the Mas chusetts State Plumbing Code and Chapter 14 .f the Gen-4) Laws. / /
By Type of License: —alt vitntir
Tltie 1 o plumber ignature of Licensed Plumber
City/Town /�.-,ICIP Master
APPROVED{OFFICE USE ONLY) ❑Joumeyman License Number: /a a 4�