HomeMy WebLinkAboutP-11-441 MASSACHUSETTS UNIFORM APPLICATION FOR PERMITITTO DO PLUMBING
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Mass. Date I I If f( Permit#gt(-144k
Pc y',• '1•1 y Building Location'51�7.IAM5 Cater" Owner's SAP-ITS
Name ANNA- S
TP e
r - : Type of Occupanc '
• t. New ❑ Renovation ❑ Replacement. Plans Submitted: Yes ❑ No7g11
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SUB-BSMT. _
BASEMENT X
1ST FLOOR
2ND FLOOR
3RD FLOOR _
4TH FLOOR _
5TH FLOOR
6TH FLOOR
7TH FLOOR
8TH FLOOR
II ��//�� n Shock one: Certificate,+
Installing Company Name 4-tC// 75/D,U t�"i"co. ®"Corporation 3c2.8/ [-
Address& R'PC1 rc/On n re./4. 0 Partnership
• S- Yet g/J'7CVVi) /290„ 0266 41 ❑ Firm/Co. / 1
Business Telephone SIDS - S 9Li- 7771 , ACCEPTED r k
Name of Licensed Plumber g1(
INSURANCE COVERAGE: 1
I have a curre trliability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yesd No❑
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.
Che k one:
Signature of Owner or Owner's Agent '') Owner lid Agent ❑
hereby certify that all of the details and information I have submits or entered) • above 'licati..' are tru- -•• accurate to
the best of my knowledge and that all plumbing work and Installations p rme der the ••mi i>fued for • application will
be in compliance with all pertinent provisions of the Massachusetts State Plu b' g Code an. C•-• er 142 0 441- =n= : Laws.
By
Title Signature of Licensed Plumber
City/Town Type of License: Master EV- „IJourneyman ❑
APPROVED (OFFICE USE ONLY) License Number /��p