HomeMy WebLinkAboutP-11-608 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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wow- l �A/m Mass. Date 7/// 20_Permit# r9(1 "—*/6 d E
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Building Location a W em/ -i. —I/HT cfr Owner's Name t�17/�11 C. C/�ley
mis Owner Tell 617— ZP J--9OG C4 Type of Occupancy ppl ACC'�1�rrYLs9�/
New ❑ Renovation 0 Replacement PI Rbgttg: aA V.. !^D
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SUB-BSMT
- — - BASEMENT
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In FLOOR .
2N°FLOOR .
3RO FLOOR - - ,
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- Th FLOOR ._
"ze " _: STH FLOOR :". _ -
1_.._._..-_._... . .. 6Th FLOOR. __ __
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Installing Company Name fS 14STY i 2 vc ... Check one: . Certificate
'Address 0222 MIA—Tee/ Dri ec XCorporation 1742 C.
- EST yARMdt(ilf , MA 02473 0 Partnership
Business Telephone l .508-775—/303 0 Firm/Co.
Name of Licensed Plumber F✓M✓K w. 20Qen't
INSURANCE COVERAGE:
1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
YesAC No ❑
If you have checked its,please indicate the type coverage by checking the appropriate box.
A liability insurance policy p(, . 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 Mass.
General Laws,and that my signature on this permit application waives this requirement.
Check one:
__ Owner ❑ Agent ❑
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 • .. husetts s .-umbin4Code and Chapter;142 of the General Lads. - —"" ' - i I `
By G .. 11M44WA%I .._..... _.. _.... .A;11-'14/11; -‘ : i/GZ L:Lf�'GGV`.. . i..
t ,..I. Signature of Licensed Plumber - - -
Title (.k �` 0`�. . . f i. 1... i i
,�/;-... Type of License:Master 7ourncyman ❑ C '
, City/Town rJ4 I _ 1 , i i
77gyI
APPROVED(OFFICE USE ONL `� License Number - - _
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