HomeMy WebLinkAboutP-12-297 r•
•
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type), ^�
its, (W " Ya/Incva') , Mass. Date /a-0C 10-Zo// Permit# t'IZ7 217
4 Building Location • Owner's Name 4Arm opt) 4OS //1,01
, /9' hi,r -Mn d , L` Type of Occupancy s
New ❑ Renovation ❑ Replacement tsj^ Plans Submitted:' Yes'0' No pQ
• FIXTURES "_. v 77BS
p \.\\„ c4:\ f2 _ _z _ .
co it CC
�4,3t) 21n , ~ uj co 22I- d � yYco � VJ O - 5; rc
J VJIL � 2 ILI
/ OtZCCILwW � og rnzoo�2c0z � o_cco
cc J — O m
al\ � c=iq � Qiazcol- c- O zzecPOYw
Y J Z LU J 2 f— 03 Le 0 0 c lx tr O
SUB-BSMT.
BASEMENT
1ST FLOOR
2ND FLOOR ,.
3RD FLOOR
4TH FLOOR
5TH FLOOR •
6TH FLOOR
7TH FLOOR _
8TH FLOOR • •
;heck one: CertificAte
Installing Company Namels,/n InskiI//Z�p. ttorporation -Fag/
Address 6 ?ev rth,, n r/'_/� . / ❑ Partnership
• -S'- )/a.err7ouV O ine 02665J ❑ FlmvCo.
Business Telephone 'ST) 94- 7778
Name of Licensed Plumber
INSURANCE COVERAGE:
I have a currept liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yesli 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.
• Chtk one:
Signature of Owner or Owners Agent Owner 14' Agent P
I hereby certify that all of the details and Information I have submitt:• . entered) I ab ve :ppli•ation are tru: : • accurate to
the best of my knowledge and that all plumbing work and installatlo •erformed undo a pe • Iss :d for appli :tion will
be In compliance with all pertinent provisions of the Massachusetts State - •••bi e any pt: 142 • e G. :ral Laws.
By
Title '5Tgrt3Ture of Licensed Plumber
City/Town Type of License: Master Gd' Journeyman ❑
APPROVED (OFFICE USE ONLY) License Number /,7-,�}2Ej