HomeMy WebLinkAboutP-12-011 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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FIXTURES
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SUB-BSMT.
BASEMENT IRECEIVFD
1ST FLOOR • , •
• 2ND FLOOR , r. In i. 7)n
3RD FLOOR
• 4TH FLOOR a .iu.UNG DE'T.
5TH FLOOR
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•
8TH FLOOR
I �//��/, n Check one: Certificate
Installing Company Name/t ,d/i S/O40 0 S do. ®"Corporation' -3P S/ e
Address g Rea r 0/) ei it ./4... / /_ 0 Partnership
• •Z)" )ae-ineryVh el oZ(o c ❑ Firm/Co.
Business Telephone Sr/El - 394- 7776
Name of Licensed Plumber
INSURANCE COVERAGE:
I have a currept liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yesel No❑
If you have checked yes, plea indicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity 0 Bond 0
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.
Ch/k one:
Signature of Owner or Owners Agent Owner rrr�� Agent •
I hereby certify that all of the details and Information I have submi :: • entered)In abo - :police••n are true : • accurate to
the best of my knowledge and that all plumbing work and Installati..s performed der t e .e ,'t• sued for i application will
be In••'ance with all -= inent provi- ons of the Massachusetts Stat= - Code a,d V a•ter 142 • e Gen:ral Laws.
By `n*�101P111001
Title t LOS I Signature of Licensed Plumber
City/Town a • Type of License: Master Journeyman 0
APPROVED (OFFICE SE ONLY) License Number 7,7--Alb