HomeMy WebLinkAboutP-11-775 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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_iJ-j_ • City/Town: 1-POY+ MA. Date: dol q/ It Permit# I 77S
Building Location: 13 Go trey Q v Owners Name:(t hov/eS.era/bo$1
PType of Occupancy: Commercial 0 Educational❑ Industrial 0 Institutional p Residential g
New:0 Alteration:0 Renovation:❑ Replacement:RI Plans Submitted: Yes❑ No ria
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BASEMENT I
117 FLOOR
2ND FLOOR
3RD FLOOR
4Ta FLOOR
ST"FLOOR
6Th FLOOR
7Th FLOOR
8Th FLOOR
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Check One Only Certificate#
Installing Company Name: .JOCK Kant"
,ryt /�,./ ,rye 0 Corporation
Address: 3 f10/10tIJOygr"" city/Town: 5-�I- State: ! '/qI
Business Tel:3 9 q-a / as- ❑Partnership
Fax: prirmlCompany
Name of Licensed Plumber: Tack K got •
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INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes a No❑
If you have checked Si,please Indicate the type of coverage by checking the appropriate box below.
A liability insurance policy K. Other type at Indemnity 0 Bond ❑
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 waives this requirement
Check One Only
Owner 0 Agent 0
Signa r of ner or Owner's Agent
I h eb certify that all of the details and Information I have submitted(or entered)regarding this application are true and accurate to the best of my
Kno edge and that all plumbing work and Installations performed under the permit Issued for this application will be In compliance with all
Pe liens provision of the Masa chusetts State Plumbing Code and Chapter 142 of the General Laws.
is
By `— Type of License: i
Title t MSpg� Sig•re •f Licensed Plumber 9 lumber
City/Town . • 0 •Y Master •�r'�•�� C�
APPROVED(OFFICE USF ONLY) 51.jpumeyman Li• e Number: of P / C.J