HomeMy WebLinkAboutP-12-244 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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arnse4I, ,Mass. Date it Y 201/ Permit#"PI2 - 2y r
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_i Building Location Say l✓als�ow 1 iii • Owner's Name 7YnetwllZ /l x�f Atf�jOJt/v/
I.. Owner Tell Type of Occupancy attiring:" r
New 0 Renovation ❑ Replacement Plan Submitted: Yes 0 No PA
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2N0 FLOOR
3RoFLOOR _ NOV O V11
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41.11 FLOOR
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Installing Company Name R(STY s TNG c'?Check one: Certificate
Addressf . e2.22 Mid=Tech Drive ' , ' ::= . . ,_:,,,_.: XCorporadon < 1742 G'
V/4T YAPMmct; , MA o2473 a Partnership
Business Telephone I 5-08-77S--/303 ❑Firm/Co.
Name of Licensed Plumber FYMJK V. 2odenct
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Cb. 142.
YesDf No ❑
.' If you have checked es,please indicate the type coverage by checking the appropriate box. _ -
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 Mass. - '
General Laws,and that my signature on this permit application waives this requirement. ,
,111: '. ta_nr�/. 14S---. ,i t ',....t.,:t Check one:" '
Owner ❑ Agent ❑ _
... _ -1- r .. 1 . . . -_
Signature of Ownmegr to OwnutsAgent--_,...„..______,perforated -- ---r--- � r i 1 1 1
I g fy .. _ g rmP n I have submitted(or entered)in above application are true and accurate to the best'.of my knowledge I- 1 -
HI-
el 1 application.. rf in compliance { all pertinent I_.I I. !....
B under,the permit issued/or thus lication will be' comp Lance with
-and ufformatio
the Massacl+nsetts State)Plumbing
Code
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and flat all lamb work and install
e arta C to-142 of the General s. i � t t l l I j � � r I
By
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L__________.. .___ _.. '..Signature of Licensed Plumber 17
Title
Type of License:Master Journeyman ❑ ,
City/Town .,,
APPROVED(OFFICE USE ONLY) License Number 771'7 ..-.