HomeMy WebLinkAboutP-11-777 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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e_= t— Permit#���
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Building Location: /a totrh13-001-inA Owners Name: PAS c)co-ma-
r1r Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential ..
[{ . ) ,New:❑ Alteration:❑ Renovation:❑ Replacement: Plans Submitted: Yes 0 No ki
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SUB BSMT.
BASEMENT
15T FLOOR /
2"FLOOR ...
3R0 FLOOR
4TH FLOOR
5714 FLOOR
6TM FLOOR
7T"FLOOR
ani FLOOR `
r � . ,�,,/f�� t.t, Check One Only Certificate#
Installing Company Name: nn t W.&c l 1 ? (, -}-
G c1 ' ^ ❑Corporation
Address:4 L t 94 it S+ City/Town: t b'YF litizAtate: fl a..
o Partnership
Business Tel: 507 `17G. /510 Fax: Firm/company
Name of Licensed Plumber: 1frt I KA_ L✓—tD C t-/-
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes, No 0
If you have checked Yespleaseindicate the type of coverage by checking the appropriate box below.
ep
A liability Insurance policy. ` '"' Other type of Indemnity 0 ., Bond ❑
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 application will be in compliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General s.
By Type of License: J�
Title 0 Plumber Signature of Licensed Plumber
City/Town stet License Number: J ^ /7& O
APPROVED(OFFICE USE ONLY) meyman