HomeMy WebLinkAboutP-11-708 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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_--- 5 City/Town: /2/^rl70Ly�,�t,�� MA. Date:6/1 3/( ( Perm/it# —�]D p
Building Location: , e 1;62UnT rSd; Owners Name: �Y4'/750-r7
PType of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional 0 Residential[9---
New:❑ Alteration:0 Renovation:[r Replacement:0 Plans Submitted: Yes 0 No❑
FIXTURES
DEDICATED
Z 1 l i liv iE SCS SYSTEMS
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� i _ s. � 5� ; MAY ' 3Z011
c p a , a a G s- c 3 e i N Z 9 0� _ BUILD NG DEPT �I 4 Q
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W Y d 8 3 = = Q 0 3 . Y Z = F m ��jj I 16 yQ W 3 ,,,
11122 `�! 5 3 rc H N 3 3 0 !(It .9a W W
SUB BSMT. (,h
BASEMENT
1sT FLOOR
2Na FLOOR
Spa FLOOR
4Th FLOOR
STN FLOOR
6Th FLOOR - - --
7Th FLOOR
8Ta FLOOR
Installing Company Name: S Sfl 744,
Check One Only Certificate#
❑Corporation
Address: P(d.g//ev- 67L City/Town:)47ACI
State:n/70'
❑Partnership
Business Tel: oZt 02 3`/g/76-- Fax:
B,_
tinn/Company
Name of licensed Plumber: `WJ4r .r/h%Sserfr4
INSURANCE COVERAGE: /
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 Yes Q4 ❑
if you have checked.Xj,please Indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy 1" 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 waive%this requirement.
Check One Only
Signature of Owner or Owner's Agent Owner 0 Agent 0
I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the bast of my
Knowledge and that all plumbing work and Installations perfonned under the permit Issued for this application will be In compliance with all
n nt provislo Ne assachusetts State Plumbing Code and Chapter 142 of the Gene Laws.
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By r g` Type of License: /fir
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Title ...p'& ` ,! "gnat e o Licensed Plumber
—� CI Plumber
City/Town l : 6 . EB taster
APPROVED(OFFICE U' ONLY) ['Journeyman
Number: //