HomeMy WebLinkAboutP-12-043 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Pri t or Type) Zp 2 3
�_ 1b2frleid , E , Mass Date 6779 41� __ Permit
s •r Building Location /7 / /t • go/ . Owner's Name Ma Ca 4f ..I�AY—
_..isO! a, M . ,?.Sat Type of Occupancy R•o S
R. New ❑ Renovation ❑ Replacement ' ' Plans Submitted: Yes U NOS
FIXTURES
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SUB-BSMT.
BASEMENT _ •
1ST FLOOR .
' 2ND FLOOR •—•-?----_ ----7
r 6 �^
3RD FLOOR
4TH FLOOR Ill ? ? 9011 2)
5TH FLOOR _ .
6TH FLOOR BU LONG irr-�-
_.._. . 7TH FLOOR 132....„___-----__ --
8TH FLOOR
I ' C�ck one: Certifi e
Installing Company Name.fre --G�J1S/D� 41-eO. ®'Corporation 3 a [,+
/1
Address g O rc/O/) L'/I.7'_1 . 0 Partnership
• •ZThe )4it-n- uc/1/h n9 oz( 6 V Firm/Co.
Business Telephone SIDE, - .9Li- 7778
Name of Licensed Plumber
INSURANCE COVERAGE:
I have a cure"'liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yest2f No❑
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 application
waives this requirement.
• Che k one:
Signature of Owner or Owner's Agent �-- ) Ow _r rrAgent a
I hereby certify that all of the details and Information I have submitte (or entered)In above :••licati• are tru: . , accurate to
the best of my knowledge and that all plumbing work and installation rformed un the p. it i.ued for application will
be I. om;'hance with all pertinent provisions of the Massachusetts State I de an •ter 142 o e General Laws.
By 1jtlilA��::
Title IV S - = _ Signature of Licensed Plumber/
City/Town • • • Type of License: Master 0' Journeyman ❑
APPROVED (OFFIC USE ONLY) License Number /nib