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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type) (^'
V?a t \IGrmaxaIVh ,Mass. Date Ott l k\ 20 Permit/ l ' (( 7
s
- t Buildin Location\C\ v\C, �.na. Owner's Name \\ t�\ Q\
�`-- a' Mc..cMOU e` s
aOwner Tell Type of Occupancy Res
New 0 Renovation 0 Replacement @L Plan Submitted: Yes ❑ No In
FIXTURES
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P
r o y WW�
y [Y F U y a
ico
STIR-BSMT ) {!ri ile_
j i 1i, {11
BASEMENT I l I1
Ira S
FLOOR :.p ?l ll
2"D FLOOR
30.D FLOOR L.liLt11A'.
4Th FLOOR -- -
STM FLOOR
6T"FLOOR
7T"FLOOR
RT"FI f OR/'J? �
Installing Company Name! ,e/ /1 'L!/Al// /U'J l J/M Check one: Certificate
Address 171 /Wisp, J2 g f )(Corporation
fl iken/l j 444 a' zesq 0 Partnership
Business Telephone l g)VC 4'a-t Leduc 0 Firm/Co. '
Name of Licensed Plumber
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 yrs,please indicate the type coverage by checking the appropriate box.
A liability insurance policyJIC 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 Mass.
General Laws,and that my signature on this permit application waives this requirement.
Check one:
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)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 Massachusetts State Plumbing Code and Chapter 142 of -e •ml Law
By '. _
Signature o Licensed Plumber
Title
Type of License:Master Journeyman 0
City/Town
APPROVED(OFFICE USE ONLY) License Number 41c9-969