HomeMy WebLinkAboutP-11-752 • MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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E =a' City/Town: S. Y LAA MA. Date: 68/! (( _ Z.
_J•.('� r Mr:(AL;
'I Permit# 1�
Building Location: W / WctnwpcWtOa9 Or. Owners Name: ()Ors , `IQnC e.y
pType of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential
New:❑ Alteration:❑ Renovation:❑ Replacement:le Plans Submitted: Yes❑ No❑
FIXTURES
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er FLOOR
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3 FLOOR
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6TH FLOOR BY_ -- —,
7TH FLOOR
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I)l v A/)/ Q. 1 Check One Only Certificate#
Installing Company Name: P n /1 i"�r, P-1- Ltc_ ��
1 (� `/ B Corporation a S68c.
Address: n CpaaSa PcJICity/Town: U , 7r,rwn , - state• Mq
i 0 Partnership
Business Tel:C400 771-4 5 5I Fax: 0 Finn/Company
Name of Ucensed Plumber: )'CC✓,n ! / r VI'c4e
INSURANCE COVERAGE: (''
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes Tar
0
if you have checked 'e ,please Indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy a 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 142 of the General Laws.
By Type of License: aWse
Title ❑ lumber Signature of Licensed Plumber
CiyRown Yei Master
APPROVED(OFFICE USE ONLY) ❑Journeyman License Number: I I bac)