HomeMy WebLinkAboutP-11-701 ?NILb(c 5= 1 (- 1( .
t MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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==1f_ City/Town: (2(y. M��� MA. Date: S/ I l / 1 I Permit#
Building Location/y AAr/70w '.5-j Owners Name: Nil likue. 9rdp.osY-ltj
PType of Occupancy: CommerciEducational 0 Industrial 0 Institutional 0 Residential 0
New:0 Alteration:0 Renovation:,- Replacement:In Plans Submitted: Yes 0 No❑
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SUB BSMT.
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2N0 FLOOR
3d0 FLOOR
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6'"FLOOR
7TH FLOOR
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(vt cerl"." .--)fl"--Al- Check One Only Certificate#
Installing Company Name:
Corporation
Address: 0(3°GC 2d26 City/Town: J� �
State:
_ 0 Partnership
Business Tel:_COt'3KS Si770 Fax:
� r ^ 0 Firm/Company
Name of Licensed Plumber. 'R ` -(ZA 0(1 c iv
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 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 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 performed under the permit issued for this es Ie III be in compliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of enero
By ' Type of License:
Tine 114sppi 0 Plumber Si nature/of Licensed Plumber
Cry?own T' O • ❑Master /
APPROVED(OFFICE U E ONLY) ❑doumeyman License Number. /� 3