HomeMy WebLinkAboutP-11-439 MASSACHUSETTS`( " � noYp,j, UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
VV un-t , Mass. Date'JAM (1 I I Permit#.1(-439
fr. ''�i'-.:L , Building Location IAl- .ZT+1f �k(1E Owner's NameaANISARA
Al" ' A klOA Type of Occupancy EtS(2EG
• =it' New ❑ Renovation ❑ Replacement Plans Submitted: Yes ❑ No '>c
FIXTURES
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SUB-BSMT.
BASEMENT X
1ST FLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR
5TH FLOOR
6TH FLOOR
7TH FLOOR
• 8TH FLOOR
II f/� /� C ck one: Certificate�+
Installing Company Name ff,fafS/Od) t1 4 O. re—Corporation -30'2c f ("
Address 8 -Pa rc/vr) r//eft JE ❑ Partnership
. Z'- )/ci n-701/1110 ma 0266 V ❑ RmVCo. (1/.
Business Telephone SID --Sig- 7778 pgCn°
Name of Licensed Plumber _
INSURANCE COVERAGE:
I have a currep%liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes VI 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.
Che k one:
Signature of Owner or Owner's Agent Owner rAgent ❑
I hereby certify that all of the details and Information I have submitted , :Trod)In abo . ••plic• on are true •ad accurate to
the best of my knowledge and that all plumbing work and installatio• performe• under e •er ' issued for I application will
be in compliance with all pertinent provisions of the Massachusetts Sta : - ' g Code • • ,/pter 142 • : General Laws.
is
/
By
Title Signature of Licensed Plumber -
City/Town Type of License: Master Gd' Journeyman ❑
APPROVED (OFFICE USE ONLY) License Number 7,7-216