HomeMy WebLinkAboutP-11-046 -
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
C-.M,�E pit-04k,
C =i=:e CT/U'/� Permit#
`e lr— a City/Town: /Sid/ Arita MA. Date:
Building Location . - - a �' t.a t. Owners Name: e, WU i .
alType of Occupancy: Commercial❑ Educational E Industrial❑ Institutional❑ Residential
New:0 Alteration:0 Renovation:❑ Replacement:171'...---Plans Submitted: Yes❑ No
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FLOORsaae‘s x,12' —
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Check One Only Certificate#
Installing Company Name: C F t 1u/ I/SLOW/ 1NP Corporation ih.2s
Address:2,&n/eDOA/ &tit City/Town: el. 14/2.016077/ State: MA 0 Partnership
Business Tel: 505t 39V-7778 Fax: SOS SQ4 ' 8a-S% 0 Finn/Company
Name of Licensed Plumber: E. P W24/51.610 3227.
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes No 0
If you have checked Yes.please Indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy V Other type of indemnity 0 Bond 0
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 0 Agent ❑
Signature of Owner or Owners Agent
I hereby certify that all of the details and Information I have submitted(or entersgarding this application are e and accurate to the best of my
Knowledge and that all plumbing work and Installations performed under the pe it' >• fort is application (ir be in compliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 14 of t e1G- eral aws. ti
/ I/
By Type of License: 1
Title 0 Plumber Signature of Licensed Plumber
0 oureyman Master
ARLicense Number: VIM 9
APPROVED ❑Joum(OFFICE USE ONLY)