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HomeMy WebLinkAboutP-11-794 ICO t1 4-0irr6- 1l- 1l ote , MASSACHUSETTS UNIFORM APPUCATION FOR PERMIT TO DO PLUMBING 6. i =mil=lift City/Town. \f Mel 6 7" ,MA. Date: 4�/5�J 1 Permit# I —7i�� ,4„,.....,. //'' / (J / ,//� Building Location:'7S SIS 9,4 all° Pi? Owners Name: ©/ / dCid/ PType of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential g. New:9 Alteration:13 Renovation:9 Replacement:n Plans Submitted: Yes❑ No❑ lr__ FIXTURES DEDICATED ?Ali SYSTEMS reW Z -. •. rt--.: N :J O Z ul t.' V c ? N - 2 N N uN� S N p C r- C C Z a Y Y 7 lJ ID K Q� Z CC „ 2 - W_ 1I� QQ re 2 N Z a 2 (g Z_ 71� ke I.� N W H 4 3 1/� p K W N ~ W 6a: c V N S 1 X A a fC • Q �� ? JO m Q N O Q W Ce O Q W Z W J 'Z_ LL' 2 W Q W x x = p o 3 = Z < " 3 a Y z = � W d l a N it f- L:�–�s=i m m c o x x 5 5 z h I r- E 3 3 3 Oa is a s 3' SUB BSMT. BASEMENT / / 1sT FLOOR 2Ne FLOOR 3"FLOOR 4T"FLOOR ST"FLOOR 67"FLOOR 7T"FLOOR 8T"FLOOR n Check One Only Certificate# /�iIn. Installing Company Name: L� f L Oot /v(Gh�p a/ c1/26441 n Corporation Address: 9>f O1 4"/) tali CityfTown: state,9/T ❑Partnership Business Tel: Jed P 3'4, 1,7,- Fax: ❑Firm/Company Name of Licensed Plumber: r/ / 4 -554--AA) INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 Yes 0 No❑ , If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy 0 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 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 ork and installations performed under the permit issued for this application will be in compliance with all • 'm-•t provislo se Massacsetts State Plumbing Code and Chapter 142 of the General Laws. By `w .._ I. WO:L...- , Type of License: r Title 110 sr Ai[/C Floumeyman ber Signature of LicensedPlumberaster Cityrtown r_ .i l License Number. Z /erUfjr� APPROVE• (OFFICE USE ONLY)