HomeMy WebLinkAboutP-12-081 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type)
I i s. _/ Wear yormb1& ,Mass. Date 3/9 20 (I Permit#`pia -1
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int_ Building Location b' /174 �fR� /P'L Owner's Name �Gm°S/- K�f. 'r,7'�/
Owner Telt/ 15i8) 7 yo--if}f Type of Occupancy ��/ ota
New ❑ Renovation ❑ Replacement)c ( Plan Submitted: Yes 0 No tom'
Cni pFIXTURES /
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W 410. p. o ay aa
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SUB-BSMT
(�'O BASEMENT /
n • In FLOOR
2N0 FLOOR
3P0 FLOOR
‘11.. 4Th FLOOR
*r 5Th FLOOR
6Th FLOOR
7Th FLOOR
ATM Ft OOR
Installing Company Name Rusry 4 Z'Mc Check one: Certificate
Address eZR2 Mid—TecA Dr)✓G $Corporation 1762 C
Wer yAf$Gtf/1r , PIA 02473 ❑Partnership
Business Telephone# Cos-775--1303 ❑Firm/Co.
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Name of Licensed Plumber Ft MIC W. Rodenec
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
YesNo ❑
If you have c ecked r_s,please indicate the type coverage by checking the appropriate box.
A liability insurance policy r 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.
Check one:
Owner ❑ Agent 0
Signature of Owner or Owner's Agent
. I hereby certify that all of the details and 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 General Laws.
By CNK W.
Signature of Licensed Plumber
Tide y
Type of License:Master P Journeyman ❑
City/Town 77 y
APPROVED(OFFICE USE ONLY) License Number