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HomeMy WebLinkAboutP-11-621 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING pt_ (Print or Type) / MM y� .Mass. Date`s 201/ Permit#tt( -C49-1 L'// F I N �. � �[L^,n, Owner's Name �le� Building Location �elSsllx e_ 1 1° 5 %lire Owner Ted# Type of Occupancy 'AY genhr^-'r • New 0 Renovation ❑ Replacement b ' Plan Submitted: Yes 0 No O..• P ...z., FIXTURES 4 "1 rZ r F Li tel Z< O Z Z L>'a w N :C rat K a _V (.' 2 O Z Z Z y F z w r rat V 3 x • Ci Z O z c H < x y U rat X a U ¢ a rt N N C < H Z G. 6 Z K a. 8 O tZ Q e. O Z Z < F > r. O < tU- y i.e.,H 1 < I 6 O, s < C 2 1 .7 O < F 3 u m n o o S 3 z n u c� 221 c 3 a_ w o • SUB-BSMT R E . BASEMENT I _• % 1ST FLOOR OF 1 4 20 1 . ;r . - 2"'FLOOR • 30.D FLOOR • rib gb,'LI r 4T"FLOOR . 5"FLOOR . ' • • 1 &T"FLOOR ' ;. t 7"FLOORi _ RT"Ft OOp • • ra Check one: Certificate • • r Installing Company Name _t AID 1 al ,s:a I I/ t I. le 'Address 5 1 l 4ec v .. L"'Co(rporadon tQ�C• *wait rnf` 1 �a/�u'nCt 0 Partnership • Business Telephone N 5023-3(45-60 I�-� • 0 Firm/Co. Name of Licensed Plumber a -v� �/v�t(il • ' INSURANCE COVERAGE: • I have a current Ii i Ity insurance policy or as substantial equivalent which meets the requirements of MGL Ch. IC. • Yes No ❑ If you have checked vex,please indica e type tuverage by checking the appropriate box. ' A liability.insurance policy Other type of indemnity 0 Bond 0 - OtiViJER'S'rN'SUR7TNCE-W7:fVERy-h'm'awarethat-theiicensee dues nnr-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 pne: . ' Owner 0 Agent 0 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 th all plumbing work and'retaliations performed under the permit issued for this application will be in compliance with all pertinent provisions of th-alt huset s ski I moi 'Code and Chapter 142 of the G . Sign ••-e of is used Plumber Title 1.S �' " r �/ pc of License:Master O" Journeyman ❑ '•`t''.: City/Town /t -Vtr\O : /Li ?�rr • "APPROVED(OFFICE USE�ONLY) License Number I �� /yl� x U._F