HomeMy WebLinkAboutP-12-151 ... �. �tra-H e• la- liar..-1 t 1212.—
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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1;1_ �City/Town: MA. Date: �An P Permit#� - 1 Sr
Building L cation: // J/JOS ti or- Owners Name:t?i( /1 44%
PType of Occupancy: Commercial❑ Educational❑ Industrial p Institutional�] Residential
New:❑ Alteration:❑ Renovation: Replacement:❑ Plans Submitted: Yes❑ No V
FIXTURES
DEDICATED
i SYSTEMS
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SUB BSMT.
BASEMENT /
1st FLOOR / I f
2" FLOOR .• 1
3"FLOOR
4T"FLOOR
5T"FLOOR
6T"FLOOR '
7T"FLOOR
8T"FLOOR - .
/ (i921 Check One Only Certificate#
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Installing Company Name: ' r/2o-71A41/ n
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0 Corporation
Address:/* j 1 t, .'et_ it tty/Town: /y 4 Stat & 0 Partnership
Business Tel: &'P 7,1 r� ' Fax:' Irm/Company
Name of licensed Plumber: /2 6Y,
INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 Yes irrio 0
If you have checked in,please Ind! to the type of coverage by checking the appropriate box below.
A liability insurance policy 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 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 permit issued for this application will be In compliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter of_the General Laws.
By Type of License: 8 'J4 .L
Title ❑Plumber Sign a of 1.cen_sed Plu err
Master
City/Town 0 oumeyman Licens iilmber ��2 '%[/0
APPROVED(OFFICE USE ONLY)
SEP n R 2011
00
11/1 , _94GD P/2O
By: