HomeMy WebLinkAboutP-12-307 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING bp ay
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.Mass. Date I 1/2., 20JLPermit r" �Z" 301
1 ci, _ = ,` 31 C0-14-0.3, RV6�d. Owner's Name_(Lark 4-u
__ Building Location
a• Owner Tell5:4 /Aj--.95Raa5 Type of Occupancy AS
New 0 Renovation 0 Replacement Plan Submitted: Yes ❑ No 0
FIXTURES
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• SUB-BSMT -
• BASEMENT . _ .
• ' • 1ST FLOOR .
2"e FLOOR •
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30.0 FLOOR • •
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... 4T"FLOOR • _ - .. .
STM FLOOR , - •
' 6T"FLOOR ' •• .
.,.' • :7T"FLOOR
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PI F1'ono ' • I'
• •.. Installing Company Name r "'"O T 14;44 l j 4( 11 if Check one: Certificate
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Address ��� tPS ( � t poradon ;025-5.
• 5 *inn , AAGtiet 0 Partnership
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• Business Telephone# ?fl9 Cho 1 Ct( c�? -3� Sa7) 0 Firm/Co. •
Name of Licensed Plumber vv 1nijeilM 12 . •
INSURANCE COVERAGE:
• I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. •
Yes Nu ❑
If you have checked yes,please indicate the type coverage by checking the appropriate box.
A liability insurance policy ❑"./ Other type of indemnity ❑ Bond 0 •
- -OWNER-S-I'NSURA-NCB-WA7'7ERi-Parrraware-dtatnhetieensee.dnes.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.
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Check one:
Owner 0 Agent 0 •
Signature of Owner or Owner's Agent - .
I hereby certify that all of the details,and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for i' ' clan will be in compliance with all pertinent provisions of
the Massachusetts State Plumhine Code and Chapter 142 of the Gene -
By E
' Signam ••t'icensed Plumber
Title ‘
• •' ' • ' r- f License:Master r7//� Journeyman to
•:r.0..: APPROwn �5L(o_ •
•`' ts'"" •CAPPROVED(OFFICE USE.ONLY License Number