HomeMy WebLinkAboutP-11-394 •
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
Print or Type) L Z�/ / Q(
Y , 7 Mass/. Date /V-O•3 1S. - - Permit# (-39
0. ::3.:-: ,..- . Building Location 8V 1/c414t/j/) e ftC Owner's Name /MA• A 2
u) *win du h Typeof jOccupincy ,, -.
(t New 0 ''•-Renovation laReplacement I - Plans Submitted: Yes ❑ - No
FIXTURES r�
o1 di)ic wN co Id -Iro
tZ 03
o CO irc
z ¢ JpN05rico '.
O/ � mw =Era ¢ I�— goWWFC � CI-
sscc � a u- aga 4ty
. 6v ccW O z W d co ccm c g UJ a J zcc ci-❑ ❑ OLL
— —i
✓1 to F- O I-- �c Y u-
c 1- ' q _ co co d < O d O Q d E ¢ tS c O d I-
Y J m rn ❑ ❑ J S F— rn tL O = ❑ d 3 ccm O
SUB-BSMT.
BASEMENT )
1ST FLOOR
2ND FLOOR ,
3RD FLOOR •
4TH FLOOR
- 5TH FLOOR tti• ----..-"—
6TH FLOOR 0
7TH FLOOR
8TH FLOOR
y� Cck one: - (+
Certificate•� ,
Installing Company Name A:Ivamind
I ndI PIA ea. tCorporation 3p�8
Address 6 gee?rcwn ("ire/4. /- ❑ Partnership
• Z- ycr,e/rnuu/VA / OZWo V ❑ Firm/Co.
Business Telephone S7DPI - 394- 7778
Name of Licensed Plumber
INSURANCE COVERAGE:
I have a currept liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes 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.
Chek one:
Signature of Owner or Owner's Agent / 0 ner rrt�� Agent s
I hereby certify that all of the details and information I have submitted r enter-• n ab. : appli•.tion are tru: •nd accurate to
the best of my knowledge and that all plumbing work and Installations .t :17cl nde -- pe fit issued to is :.plication will
be In compliance with all pertinent provisions of the Massachusetts ":13 ,f Bing Cod/• • .• er 14 .1- he ene al Laws.
By '_dd"
Title Signature of Licensed Plumber/
City/Town Type of License: Master rd' Journeyman ❑
APPROVED (OFFICE USE ONLY) License Number in-,15