HomeMy WebLinkAboutP-11-440 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type)
Wanni`L , Mass. DatecaN1 li Vi& ( I Permit#n«_,7 qO
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Building Location WEST" U1IG5 Owner's Name -
yAenau��'P- Type of Occupancy (12 -7\1-W"=�E New ❑ Renovation ❑ Replacement Plans Submitted: Yes ❑ No)�
FIXTURES
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SUB-BSMT.
BASEMENT X
1ST FLOOR
2ND FLOOR r
3RD FLOOR _ •
4TH FLOOR
5TH FLOOR
6TH FLOOR _
7TH FLOOR _
8TH FLOOR
_ // Pile
- Sack one: Certificate
installing Company Name,tirta 15/OwU it C O. Corporation -3c2 ce/ (I
Address g ?CLQ rclvn �/re__/g.... / /- ❑ Partnership
• Z)" ycr,,�c j,Vh in& OZI ❑ Firm/Co.
Business Telephone Sad-S91-1- 7778 tattPZEO
Name of Licensed Plumber
INSURANCE COVERAGE:
I have a currepf liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes WI No ID
If you have checked yes, plea indicate the type coverage by checking the appropriate box.
A liability insurance policy 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.
C_he k one:
Signature of Owner or Owner's Agent Owner Gd Agent ❑
I hereby certify that all of the details and Information I have subm' S(or enter:. in above .••licati•• are true an• . • rate to
the best of my knowledge and that all plumbing work and installati•• pertorm`:/under the • .rmit Iued for this .•• ation will
be in compliance with all pertinent provisions of the Massachusetts Stat. 'lu AC•g Code . a.'er 142 of th: eral Laws.
By .`
Title gnature o Licensed Plumber
City/Town Type of License: Master Journeyman ❑
APPROVED (OFFICE USE ONLY) License Number /,77-9
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