HomeMy WebLinkAboutP-12-027 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or_Type)
• y�1z MO IJ , Mass. Date i f� 1R " Permit# 2-62'7
Building Location Hon SU Jw�yOwner's Name SCS / P
+� 7S�' �3 n Type of Occupancy •
It New O Renovatio ❑ Replacement's Plans Submitted: Yes ❑ No ❑
FIXTURES IIJ)-
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SUB-BSMT.
BASEMENT
1ST FLOOR
• 2ND FLOOR
3RD FLOOR
4TH FLOOR
5TH FLOOR
6TH FLOOR •
7TH FLOOR
• 8TH FLOOR
Deck one: ertificaf e
Installing Company NameM'-taJDS/Ot)fot t�0. Corporation -_?2 (-
Address g K&?rc2b/1 ('.'t2t 14. 0 Partnership
• s'- lace/nCJ(/se!7 inek UZlolo 4 ❑ FimmCo.
Business Telephone SZDS'-194- 7778
Name of Licensed Plumber
INSURANCE COVERAGE:
I have a currepf liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
YesYes0 No CI
If you have checked yes, plea indicate the type coverage by checking the appropriate box.
A liability insurance policy 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 as plication
waives this requirement.
• Ch. kon-.
Signature of Owner or Owner's Agent Owner rc • .en ❑
I hereby certify that all of the details and information I have submitted •r entere• In abo e pplic-tion ar: tru: -nd accurate to
the best of my knowledge and that all plumbing work and Installations •:rformed udder the •: • issued or is application will
be in compliance with all pertinent provisions of the Massachusetts State • •i, Code : pter 14 • the eneral Laws.
By
Title Signature of Licensed Plumber/
City/Town Type of License: Master Gd' Joumeyman ❑
APPROVED (OFFICE USE ONLY) License Number 7n,�j