HomeMy WebLinkAboutP-11-625 vouciL N Oicik,o-il gle_
MASSACHUSETTS UNIFORM APPUCATION FOR PERMIT TO DO PLUMBING
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: I( City/Town: 159 f 5'\ ��u C aw 11/4\ 1 �
MA. Date: I Of I ll Permit#�I1 — (:,a <
Building Location: V\ ,. vvto'F Owners Name:0-e t%ear..!;•'
PType of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional 0 Residential
�� New: • Alteration:0 Renovation: KtReplacement • Plans Submitted: Yes • No •
WO — a' FIXTURES
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,' DEDICATED
a Z SYSTEMS
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SUB BSMT.
BASEMENT
1'T FLOOR I t I
2ND FLOOR
3"D FLOOR
4T"FLOOR
5T"FLOOR
6Th FLOOR
7Th FLOOR
BT"FLOOR
�Or TNI , l+ 1 y Check One Only Certificate#
Installing Company Name: 1 ' J t' L t
Address:( a Nc� 8O5 k DWI')I') A ❑Corporation
4/City/Town: State: �
❑Partnership
Business Tel:fret.) 36/-1 Y“' Fax:
0 Firm/Company
Name of Licensed Plumber.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes 0 No 0
If you have checked kg,please Indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy 2 Other type of indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER:lam 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 waive%this requirement.
Check One Only
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)regarding this 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 provision of the Massachusetts State Plumbing Code and Chapter 1429of the General Laws.
8��e Type of License: le)/44
Title 1 k)S p r 0 Plumber Signature of Licensed Plumber
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Ciy?awn[t • 13 Master
APPROVED OFFICE USE ONLY) ['Journeyman License Number —11.3-4