HomeMy WebLinkAboutP-12-200 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING(yei„bD.
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Inc-- :/ yorMooll port-r .Mass. Date _20 Permit ft P(1,.. 200
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( eI_- _ re Building Location _a I \ )[y P1 Owners Name `
Owner Tell .3f02 2 4 Type of Occupancy
` New 0 Renovation 0 Replacement t� Plan Submitted: Yes 0 No n— . .a
FIXTURESir . E C E (� r. f 'i `
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SUB-BSMT
BASEMENT , II
' 1sT FLOOR •
2He FLOOR
3"FLOOR •
4TH FLOOR .
STM FLOOR
. : • I 6TH FLOOR
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TPI FLOOR
RTM Fl OOR
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•',Installing Company Name 6110N1 t ►rp.I(/I vsit '\/lj Check one: Certificate
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Address ("0114,05- t pr tk \'J oration
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• S..*nom* MA- _roc,6L( ❑ Partnership
• Business Telephone i/ . 1:18-CIAO 1 Czt( 0)-360^$')-77 0 Firm/Co.
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Name of Licensed Plumber vv$�ftie CL2
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INSURANCE COVERAGE: - - - • - - - •
I have I current lia,b.dlity insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. •
Yes No ❑
If you have checked yes,please indicate/ the type coverage by checking the appropriate box.
A liability insurance policy O'" Other type of indemnity 0 Bond ❑
'" -OwNEICS-INSt7RNNCE wAIVER•,-t-- -aware-that-the-ficensee-does-not-h:ve the insurance coverage required by Chapter 142 of the Mass.
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General Laws.and that my signature on this permit application waives this requirement.
Check one:
• Owner 0 Agent 0 •
Signature of Owner or Owner's Agent
I hereby certify that all of the detailsand 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 r' ' tion will be in compliance with all pertinent provisions of
the Massachusetts State Plumbing Code and Chapter 142 of the Gene �"' /
By
' Signaru •/tcensed Plumber
Title 1
• • r f License: Master 0-""----- Journeyman ❑
• City/Town
`APPROVED(OFFICE USEONLY) License Number is^ �,.,c