HomeMy WebLinkAboutP-11-480 Meir 156 1.3€1
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
a; '=Jr / City/Town: itieten Il MA. Date: iyy // Permit#�Rt� — '1
Building Location: c i2 Sr otkt1 2K3�v7cp Owners Name: Ro - IBA o '.4rv--
PType of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential Er
New:❑ Alteration:❑ Renovation:❑ Replacement:�ans Submitted: Yes❑ No❑
FIXTURES
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SYSTEMS
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BASEMENT n1 . - r1 I I5 Irl
in FLOOR / / / _,�' !n
214°FLOORill FEB {) 4 ZOit "' '
t°FLOOR •
4TH FLOOR II
STH FLOOR
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7TH FLOOR
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.�/ Check One Only Certificate#
Installing Company Name: AJ50 Yeeh//estG e/
c��O ❑Corporation
Address: �• . 0364e.. 332 city/town:A: t)/ie/!i' state:/7,4-
p q C ❑Partnership
Business Tel: 60 d.37.,-/,SJFax: �O 41326/6-7 ❑Firm/Company
Name of Licensed PlumberT" fdC AA se-7471
INSURANCE COVERAGE: �
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 Yes 0no 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 ❑
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 ❑ , 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 nem*Issued for this a•plication will be In compliance with all
ent provision of the Massachusetts State Plumbing Code and Chapter 14 .1 the General Law
BYcOTZr � t Type
of License: ,/"J „�-ill .
tar
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`� CT ra$"mber Sig ature : Licensed Plumber
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APPROVED(OFFICE USE ONLY) ❑doumeyman License Number: /«t<(�O p�