HomeMy WebLinkAboutP-12-024 MASSACHUSETTS UNIFORM APPLICATION OR ERMIT TO DO PLUMBING
,y II k1hOL POS, Mass. Date 3 Permit# "tit—e)24
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I{ Building Location 3;D f //�E ,&-t_ - Owner's Name {7,Nk77AJ— f S7US
Owner's Phone# 1 .3 9 4 x,44 go Type of Occupancy Residential
PNew 0 Renovation 0 Replacement QX Plans Submitted: Yes Q No QX
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SUB-BSMT.
BASEMENT — --rI
— 1ST FLOOR .( ,4 1t:__5 1 c 12 II74-
2ND
L2ND FLOOR 1
3RD FLOOR FT ILLL u 7111 b'
4TH FLOOR
5TH FLOOR _ BUI.DING DEDT
6TH FLOOR Ly 1
7TH FLOOR
8TH FLOOR
Installing Company Name Bath Inc./Area Plumbing _ Check one: Certificate
Address 25 Turnpike Street X Corporation 2430
SIIIII
West Bridgewater, MA 02379 _ Partnership
Business Telephone 508-521-2700 _ Firm/Co.
Name of Licensed Plumber Jeffrey Carlson
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL ch. 142.
Yes El No❑
If you have check yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy 111 Other type of indemnity ❑ 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 Q Agent Q
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 hath all pertinent provisions of the
Massachusetts State Plumbing Code and Chapert 142 of the General Laws.
By
Title Signature of Licensed Plumber 23,114402—L___CIty/Town Type of License: Master X ourneyman
APPROVED(OFFICE USE ONLY) License Number. 8932