HomeMy WebLinkAboutP-11-550 Pk'C7 - t' '21 3- 12- t( Pt—
MASSACHUSETTS UNIFORM APPUCATION FOR PERMIT TO DO PLUMBING
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_J-f=a• City/Town:5-1,4,7/141j� ,MA. Date: /�l/ Permit#II)
Building Location:`/' ) (�04 L/:,�1 (V,- Owners Name: // ?Kt"?d cc
PType of Occupancy: Commercial❑ Educationaluc ❑ Industrial❑ Institutional Residential 0
New:❑ Alteration:❑ Renovation:9/Replacement:❑ Plans Submitted: Yes❑ No 0
FIXTURES
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SUB BSMT.
BASEMENT / .
1sT FLOOR ( I •
2ND FLOOR
Sas FLOOR
4TH FLOOR
SIN FLOOR
6"FLOOR
7Ta FLOOR
STN FLOOR
Check One Only Certificate#
Installing Company N.me: AK / ,• Y' Jr
0 Corporation
Addres 1 i d i a� City/Town: ....t, State:
n ❑Partnership
Business Tel:r () `�f 3'7 97.2Z/Fax: 51/44" , pi- /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 Yes,please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy F Other type of Indemnity ❑ Bond 0
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
Signature of Owner or Owner's Agent Owner ❑ Agent 0
I hereby certify that ail of the details and information I have submitted(or entered)regarding . application are true and accurate to the best of my
Knowledge and that all plumbing work and installations performed under the permit issu • his application will be in compliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the G =I Laws.
yB _-42 4fir ..a)_ 14.-.21141. Type of License: / _//•d / , —,/..,
The Ks s£C 0 Plumber Signature o L en ed Plumb-1
City/Town 14IC ( ❑ylaster Z6 G
APPROV , (OFFICE USEE License Number:
ONLY)
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