HomeMy WebLinkAboutG-11-238 •
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING�/
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, Mass. Date n at&-f *9 colo Permit# p !f' Z S
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' Building Location '47 Gtr roc. Alt Vt Owner's Name 1jo43 '605tOA
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- (A) . `IAiemou-Th Type of Occupancy RES ioencc
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New ❑ Renovation 0 Replacement Y Plans Submitted: Yes ❑ No M
,:` • FIXTURES
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SUB-BSMT.
BASEMENT
1ST FLOOR
2ND FLOOR • _
3RD FLOOR -
4TH FLOOR
5TH FLOOR pa,:,It)
6TH FLOOR
7TH FLOOR _ gh"
• 8TH FLOOR
QQ . Check one: Certificate
Installing Company Name f 7ia;4c5 A. 1-1110b PLC41-1C-r ta Corporation ;3a3 g
Co_. le_
Address PA 0 Partnership
Bou 538
C t r-i tRV It-Cf: MAP Oacoaa ❑ Firm/Co.
Business Telephone 508 -11 '- Ogi
Name of Licensed Plumber C-1-1R IS C • BR t/..GS
INSURANCE COVERAGE:
I have a current liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes% No❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
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 Mass. General Laws, and that my signature on this permit application
waives this requirement -
Check one:
Signature of Owner or Owner's Agent Owner ❑ Agent 0
I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to
the best of my knowledge and that all plumbing work and installations performed under the permit Issued for this application will
be in compliance with all pertinent provisions of the MassachuseSt St6 ate Plumbing Chapter 142 of the General Laws.
By �t'"
Title Sig ure of Licensed Plumber c
City/Town Type of License: Master ri Journeyman 0
APPROVED (OFFICE USE ONLY) License Number /dca I
BELOW FOR OFFICE USE ONLY •
FINAL INSPECTIONS SKETCHES FEE • PROGRESS INSPECTIONS
NO.
APPLICATION FOR PERMIT 0 DO PLUMBING
w
NAME&TYPE OF BUILDING
LOCATION &TYPE OF BUILDING
• PLUMBER
•
PERMIT GRANTED
DATE 19
PLUMBING INSPECTOR