HomeMy WebLinkAboutP-12-079 •
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING •
s9._ (Print or Type)
m--__M 3E"f t ,Mass. Date g 20 (j Permit r" pi 2—679
Building Location L {4A ed
� Owner's Name t W�
�'• Owner Telll JVJ'3 /&�o^1T1• Type of Occupancy c:LI
New 0 Renovation ❑ Replacement I✓ Plan Submitted: Yes 0 No ❑
FIXTURES
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SUB-BSMT
• BASEMENT -- I
' • 1sT FLOOR _.
•
• 2N0 FLOOR ,
3R0 FLOOR •
4T"FLOOR
• 4"FLOOR - '
.. fi FLOOR ,
1.
'4*... . 7TM FLOOR • • .. .. .. `
RmFTOOR ' ' ,1 /
•
• '•' Installing Company Name r�7flf(1 f� kCu b JJ Check one: Certificate
•
•
Address, k4eS t( J • rporation :v55(.'
`Y,f/n jk rn�- acin� 0 Partnership
• Business Telephone N 23— erg—mot ❑ Firm/Co.
Name of Licensed Plumber (/N thfliirSfa. • •
INSURANCE COVERAGE: v'' '�• •
•
• I have a current Ii ' ray insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. IC. •
Yes No ❑
If you have checked yes,please Indieat e type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity 0 Bond 0
-- -OIYNER-S INSUR:4NCL-tVA7VERS'I3rtraaare-ttmt-drclicensee-does-net have the insurance coverage required by Chapter 142 of the Mass.
General Laws,and that my signature on this permii application waives this requirement.
Check pile:
4 Owner 0 Agent 0
Signature of Owner or Owner's Agent
I hereby certify that all of the detailsand information I have submitted(or entered)in above 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 provisions of
the Massachusetts State Plumbing Code and Chapter 142 of the G
By % /,
' Sign--.•e of is nsed Plumber
Title • y
'' ' pe of License:Master ✓ Journeyman 0
..l'I;`- City/Town /'7
s �{� APPROVED(OFFICE USE ONLY) License Number I /yg-- .