HomeMy WebLinkAboutP-12-143 CHO Circum- el. wct4-) .
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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NLO U q , a s. Date / 'A3 3Ci Permit##i`L, l-( 3
,. `: s; fr Building Location 40 C-( fcD.*.E$r Owner's Name k cr'AD &Aotr 01_4_9
-.s T'7zi-• 8-4-g. &a, a-l() Type of Occupancy
. New ❑ Renovation ❑ Replacement Plans Submitted: Yes ❑ No ❑
FIXTURES
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SUB-BSMT.
BASEMENT ....n , , , . '\
1ST FLOOR kVl "o ii , ' ti. t! ;III
• 2ND FLOOR .-til __ �� �� 1
3RD FLOOR ' '"
4TH FLOOR
CLIC:''.1.C“.:..--I-
5TH FLOOR 8
6TH FLOOR
7TH FLOOR
• 8TH FLOOR
I u,g Seek one: Cert +e,
Installing Company Name ts�f•ans%di IC O. Corporation 302 [-
Address g 'ea rc/0/1 e/rd./... U Partnership
• S'- )CI.CinC/J VJ') Ina_ OZ(-06 4I ❑ Finn/Co.
Business Telephone SfE' 3911- 7 776
Name of Licensed Plumber
INSURANCE COVERAGE:
I have a currepi liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes ef 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.
CheA one:
Signature of Owner or Owner's Agent Owner le" Agent •
I hereby certify that all of the details and information I have submitt-• or entered)in a.ove ,•• icatio :re true • :• urate to
the best of my knowledge and that all plumbing work and installation- :_•ormed unde the •e 't Is;•ed for t - ...iication will
be in compliance with all pertinent provisions of the Massachusetts State Phi • . and , :p i 142 of , eneral Laws.
By /
Title Slgnamrs-orOcensed Plumber, -
CityfTown Type of License: Master ..1 Joumeyman ❑
APPROVED (OFFICE USE ONLY) License Number 1