HomeMy WebLinkAboutP-11-683 P
t MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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='%o r City/Town: Y V IMO ttk po t� `'� ' 683
,MA. Date: ' �'� -(( Permit# 1'1�
Building Location: in' gcLekgi et Owners Name: 4tV I tiLQ1 CV
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PType of Occupancy: Commercial 9 Educational❑ Industrial 0 Institutional 9 Residentiala
New:0 Alteration:9 Renovation:0 Replacement 0 Plans Submitted: Yes No
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SUB BSMT.
BASEMENT —
9 FLOOR '� '
2ND FLOOR
3RD FLOOR -
4Th FLOOR
STN FLOOR
6TH FLOOR - '
7TH FLOOR
BTH FLOOR '
n i- Check One Only Certificate#
Installing Company Name: �L1It1I4tt ms
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❑Corporation
Address: 3 a�-tetMON( City/Town: &TV.)leiel State: (MeV
0 Partnership
Business Tel: I'Pt7p 1:235' 3S9/1 Fax:
0 Firm/Company
Name of Ucensed Plumber. "\c1.--ICS gc6eitg
INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 Yes 0 No 0
If you have checked Yes,please Indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy Other type of indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER:I ant 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 ❑ 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 • 1 it lee • for this •plication will be In compliance with all
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Pertinent provision of the Massachusetts State Plumbing Code and Chap e� q1
By a_ ....1 • -..- Type of License: 1
Title 10 S erq_�,( DIS plumber Signatu of L tensed Plumb:
City/Myra • V - aster /5,994/
5 7/L/
APPROVED(OFFICE USE ONLY) ❑Journeyman License Number.