HomeMy WebLinkAboutP-11-613 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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'i— Building Location YS WO Min &Z�c.: Owner's Name 0.2/m sivf!
�• Owner Tel# 77y-7.7f—/Jf)— G# Type of Occupancy fwd/L ctX
New 0 Renovation 0 Replacement Plan Submitted: Yes 0 No
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SUB-BSMT
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BASEMENT I
I\ - In FLOOR
2N0 FLOOR
3"'FLOOR
• . 4Th FLOOR
7t 5Th FLOOR
F 6714 FLOOR
7Th FLOOR
_.. Sm Ft OOR
Installing Company Name R ti 5 TY s TN a Check one: Certificate
Address A22 Mid—Ted Dn✓t k(Corporation 1762 C.
WEST )/ARMOItllt , PA 01473 0 Partnership
Business Telephone# ,SOB—775—/303 ❑Firm/Co.
Name of Licensed Plumber Fry VIC. Rodenct.
INSURANCE COVERAGE: .
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142.
Yes X No ❑
If you have checked yss,please indicate the type coverage by checking the appropriate box.
A liability insurance policy D( 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:
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 the Geyp�ral Laws.
By &AnOC W. ainile ."._--
Signature of Licensed Plumber
Title
Type of License:Master X � Journeyman ❑
City/Town .77R'l
APPROVED(OFFICE USE ONLY) License Number .