HomeMy WebLinkAboutP-11-618 2ougL6K ' - IS- 1 (
MASSACHUSETTS UNIFORM APPUCATION FOR PERMIT TO DO PLUMBING
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=;1 r=,i` City/Town: _5 tioQ Mo LI.t.A ,MA. Date: Y(I''/l Permit#PI I – 6 It
Building Location: 20 VI Lt Ai TztPry�( Owners Name: MrG
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P Type of Occupancy: Commercial 0 Educational❑ Industrial❑ Institutional❑ Residential
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New:0 Alteration:0 Renovation:Er Replacement:0 Plans Submitted: Yes 0 No Q '
FIXTURES
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BASEMENT —
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1 FLOOR —17
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2ND FLOOR l Hrr 1 fit 1 C
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4TH FLOOR G DPT
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/ Check One Only Certificate#
installing Company Name: Me PtimAA/& j E /-rj rrmic
i 0 Corporation
Address: I C,*.MM by City/town• /.v'Vf aMfl tE5tate: M/0
0 Partnership
Business Tel: 508 246 R 3t 7 Fax:
0 Firm/Company
Name of Licensed Plumber. age,-recc, £ A M& —
INSURANCE COVERAGE: /'
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 Yes 0 No 0
if you have checked Ygg,please Indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy EY Other type of Indemnity 0 Bond ❑
OWNER'S INSURANCE WAIVER:lam 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 work and installations perfonned under the pemilt Issued for this application will be In compliance with all
Pertinenttntprovision of of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
BY\ r ""i i��`� " Type of License: e �4 %t s0ii
Title ►U9(P1Ga-W1. 0 Plumber Signature of Licensed W ber
City/Town y water
APPROVED(OFFICE USE ONLY) oumeyman . License Number. S205,R