HomeMy WebLinkAboutP-11-689 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
. .- (Prim or Type)
, r/ /0114114111- ,Mass. Date S/v 20 f Permit#?t i- egO g
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.=? Building Location SY (Yt7 4. Owner's Name 4/441 LAIC
Owner Tell (5P) 9'/`/ 4&71- Type of Occupancy ititiee it('
PNew 0 Renovation 0 ReplacementAFl
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RES Plan Submitted: Yes 0 No ey
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SUB-BSMT 55 r
BASEMENT I RLtLI1L L
. In FLOOR f, •
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2"FLOOR
MA' l b C�It
3RD FLOOR �.�.�
4m FLOOR BUILD NGJEF'�.
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It STM FLOOR .-�——y
e FLOOR
Y"'FLOOR
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Installing Company Name R US T9 Is SMG • _ Check one: Certificate
Address a2 Mrd—Talc Dove. $Corporation 1762 C
1/4657 y4RM� , /VIA 01473 . ❑Parmership
-_ __.--"Busiuess-Teiephone K 5-00 a-77 57,13 4'3 ,
0 Firm/Co.
Name of Licensed Plumber Fr rJK W. Roglen' K
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes $. No ❑
If you have checked rn,please indicate the type coverage by checking the appropriate box.
A liability insurance policy $ 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 Mass. •
General Laws,and that my signature on this permit application waives this requirement.
• Check one:
Owner ❑ Agent ❑
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 this application will be in compliance with all pertinent provisions of
th a husetts Sm slui yin, ode and Chapter 142 of the General Laws. /�
By atib7 ke \ &nit W.
Signature of Licensed Plumber
Title I YJ SP£ .
Type of License:Master X Journeyman ❑
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City/Town I ' O ' 77 p J
APPROVED(OFFICE SE ONLY) License Number / -7