HomeMy WebLinkAboutP-10-184 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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—I`�-.t City/Town• YM-ril707/ MA. Date: /90,0/2 9 Permit# i Will
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Building Location: ,4/, r �teu # 22 cS.% Owners Name: tune MYS e tr„ er-
PType of Occupancy: Commercial 0 Educational/ 0 Industrial 0 Institutional❑ ResidentialFl
New:0 Alteration: 0 Renovation: [' Replacement: ❑ Plans Submitted: Yes❑ No 0
1E_^ 7 I FIXTURES
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a m m o o u. 0 O x 5 5 re to c, 1— 3 3 3 0 0
� BASEMENT
$ 15' FLOOR / / / I /
2X13 FLOOR
3""FLOOR
4'"FLOOR
5'"FLOOR
6'"FLOOR
7'"FLOOR
S'"FLOOR
Check One Only Certificate#
Installing Company Name: 1/4254/19in,, iaiirce/ GewrneEreS
TT ❑Corporation
Address: 70•7nk cit .- City/Town: '. Deioris Stare:4V4 QPartrrershlp
Business Tel: Of.139 4/ 'C Fax:l €2257.fl a. GPS 9 0 FInn/Company
Name of Licensed Plumber: Ui0;1,v c], vir
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 Yes Olio 0
If you have checked Yes,please Indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy gre Other type of Indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER:lam 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 F,
Owner 0 Agent 0 )
Signature of Owner or Owner's 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
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By Type of License:
Tine QPlumber Si atur Licensed PI tuber
Maste
City/Town 0 oume License Number: ///,702APPROVED(OFFICE USE ONLY) al