HomeMy WebLinkAboutP-11-536 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
=;JII_ City/Town: S. V4RM D a r7-1- MA. Date: Permit#T) I"c36
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Building Location: 639 h/ittoW STA CE1 Owners Name: 6L
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PType of Occupancy: Commercial❑ Educational 0 Industrial❑ Institutional❑ Residential( (f
New:❑ Alteration:❑ Renovation:pa Replacement:❑ Plans Submitted: Yes 0, No❑
FIXTURES
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BASEMENT I
1sT FLOOR I I I I I I I
2ND FLOOR I I -f
30.°FLOOR
4T"FLOOR
5T"FLOOR
6T"FLOOR
7T"FLOOR
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���� Check One Only Certificate#
Installing Company Name: i"!/�
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0 Corporation
Address/8
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Van 1. State: 0 Partnership
Business Tet: 8.97�! 280 Fax: .9906— [Firm/Company
Com- ZQJr: ✓L1/ _
Name of Licensed Plumber:
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 yg},please Indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy .1 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
Signature of Owner or Owner's Agent Owner ❑ Agent El
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 penult Issued for Is application will be in compliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of th Gene . : .
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ByType of License: /L_
Title l.n45p4(40) _ 0 Plumber Signature of License• •lumber
Cityrrowe7LAQ'lAntr yam'LiC Master ,�A�D8�
APPROVE (OFFICE USE ONLY) ❑doumeyman License Number: /v/