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HomeMy WebLinkAboutP-11-781 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING Ini =_,_,Mie `/ / ----144:-_-= City/Town: jeinOUn Q,MA. Date: 6/7/// T Permit#P(t — 111 t. Building Location: Sr Rope- /COf/� Owners Name: /J WALL) /s6/04/21) pType of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential EX New:❑ Alteration:❑ Renovation:❑ Replacement:Or Plans Submitted: Yes❑ No[❑ Q FIXTURgS t\ DEDICATED Oi 1 Ia Z SYSTEMS J Z H OU in in W 2 n z Vi S N w 0O 0 Cg ,n ct �°yj� C Z f' Y < N tn aZ_ FL.Q Q N Z D N ft, cc f ^�. z real N z z f `^ > s O: z z ,,, V' u a x _ a a O Ou. 7 Q tx O Q W O W Q S W c'; W 41 C) W W' �2` W U i. a O 3 u 7 > O O ' Z 2 Q Q Q 0 0 Q Q a m m 0 0 u. Ox x 5 5 i N 2 I D 3 3 3 0 < 0 0 0 SUB BSMT. —R—CCEI `{7rr: D BASEMENT I _ U lrr FLOOR _ 2N°FLOORS& O 9 2011 330 FLOOR , 4"FLOOR - uutwd,c,U_NL Sr"FLOOR .nr — --------6r"FLOOR , 7"FLOOR - -, 8TH FLOOR Check One Only Certificate# Installing Company Name: .Lr/7h0/1/S/tiW /4/C ' 3a dy/ e � (l / Corporation Address:pp aAnode/4. city/Town: C S 0e/ State:/44_ �nC r1�/ o 0 Partnership Business Telt./?Zc 9'— 797a Fax: ,r22 -5Q9-(9073-4 ❑Firm/Company Name of Licensed Plumber: „/ yg/W& / A. Let/////SL.C3Cv INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes% No 0 If you have checked Ys please indicate the type of coverage by checking the appropriate box below. A liability Insurance policy [y 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner 0 Age 0 Signature of Owner or Owner's Agent I hereby certify that all of the details and Information I have submitted(or entere regarding i appli atio are and accu o the best of my Knowledge and that all plumbing work and Installations performed under the pe it issued f is appli tl ve be In co ce with all • •ent provision of theMassusetts State Plumbing Code and Chapter 142 o Gen I Laws. By .. 1 '!L1. : Type of License: Title lit 5if£0 -e-te Plumber Signature of Licensed Plumber .1-; © Muster ARLicense Number: /a 2 9? APPROVED ❑Journeyman(OFFICE USE NLY)