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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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_I L r City/Town: yememovit 2or T ,MA. Date: 3 11 {! Permit#PI I— 5--*
Building Location: C'1161MC 4 f eqd Lgt4 a Owners Name: /lartc Gr-c-t /�/�
- -- Type of Occu an Commercial
(r_ YP P cY: ❑ Educational❑ Industrial❑ Institutional❑ Residential[Ly
ry _ I New:p' Alteration:0 Renovation:❑ Replacement:❑ Plans Submitted: Yes❑ No❑
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BASEMENT I I I 3
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4TH FLOOR
4TH FLOOR
5TH FLOOR
i 6TH FLOOR
7TH FLOOR "
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Fare PIIAMY,/ r Check One Only Certificate#
Installing Company Name: y
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J Tina 94. 1 Q'Lorporatlon
�S Address:5i1tarl4 I-Cti/t City/Town: i/y am is OStaatte: i /I r
0 Partnership
Cr Business Tel: S /fp '777 76 if 5n- 72 /ad
Fax: 7 0Firm/Company
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Name of Licensed Plumber: i '/ A c ( /A/ 7 e
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 its,please Indicate the type of coverage by checking the appropriate box below.
A liability insurance policy at 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement
Check One Only
Owner 0 Agent ❑
Signature of Owner or Owners Agent
I hereby certify that all of the details and information I have submitted(or entered)regarding this 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
nt provision of the Mass,. husetts State Plumbing Code and Chapter 142 of the General Laws.
I /Y '�� ��, Type of License:
Tine HJ$VTF� C � plumber
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Signature of Licensed Plumber
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APPROVE (OFFI E USE •NL Journeyman License Number: 7�/J