HomeMy WebLinkAboutP-12-028 ti
MA SACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(P nt or Type)
YR2mot/Ih , Mass. Date e7/ 9)/ 19 Permit#P122-62S
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Bulding Location /7Z S>an.e a u-f_ Owner's Name M�EJ///1!•-• Cykf izirm.ti� Type of Occupancy C U�qy/77Z
New ❑ Renovation ❑ Replacement y Plans Submitted: Yes ❑ No 74,
FIXTURES
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SUB-BSMT.
BASEMENT
1ST FLOOR
' 2ND FLOOR .
3RD FLOOR
4TH FLOOR
5TH FLOOR
6TH FLOOR
7TH FLOOR
8TH FLOOR
Sack one: Certificate,+
Installing Company Nameitfr-zanS/DsU ter" C O. (-Corporation —3p28/ .
Address g Kea rc/on e//- .1e... ❑ Partnership
• '- lCl.C/fC/(/V`') /,C1 Uzi(c(o c ❑ Firm/Co.
Business Telephone Sn71 - S94- 7.778
Name of Licensed Plumber
INSURANCE COVERAGE:
I have a currepf liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes 0 No O
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.
Ch k one:
Signature of Owner or Owner's Agent Owner i Agent /
I hereby certify that all of the details and information I have submitt:: • entered)in ab.ye a•• atio are true/accurate to
the best of my knowledge and that all plumbing work and installati.. performed and:'the •e it is,fed forth pplication will
be in compliance with all pertinent provisions of the Massachusetts State - . ••ng C)': a d t :At: 142 of t-,Gene .1 Laws.
By
Title gnature of Licensed Plumber/
City/Town Type of License: Master 13YJourneyman ❑
APPROVED (OFFICE USE ONLY) License Number / 115