HomeMy WebLinkAboutP-12-256 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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Mass. Date /�/ / ta/�Perm #
ir. _tie R Building Location.//0 !�-i- Ai 9i S Owners Name . /tire e
/ Type of Occupancy / �J %..
r( New, ❑ c Renovation ❑ Replacement Plans Submitted: Yes' ❑ .-No
FIXTURE
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- - .. Jt4'�/ C ck one: Certificate��+
Installing Company Name .moi/IIS/OdIJ / CO: ®"Corporation 3p28 .`
Address6 Reardon diraJ4 ❑ Partnership
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Business Telephone .ZJM - J94- 7778
Name of Licensed Plumber
INSURANCE COVERAGE:
I have a currepf liability policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes 0 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 ❑
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.
Chtk one:
Signature of Owner or Owner's Agent Owner 1 ' Age• ❑
I hereby certify that all of the details and information I have submitt:. : . : d)in abo : a.plication are : and accurate to
the best of my knowledge and that all plumbing work and Inst. : ons perfo • under a p:rmit I sued • Is application will
be In compliance with all pertinent provisions of the Massachus• tate Plumb! ode an•, o a. :r 1 ' . the General Laws.
By
Idle Signature of Licensed Plumber/
City/Town Type of License: Master Gd' Journeyman ❑
APPROVED (OFFICE USE ONLY) License Number /7;1115