HomeMy WebLinkAboutP-11-691 0 66els
� MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING •
• �
yormat(Prim or Type) rfn— ,/, .Mass. Date t�/ll 20 /( Permit n [l ` W Ql I •—I I= Building Location
r,A At666 Owner's Name iG
�.,ir:••• Owner Tell ( 9. Type of Occupancy 4 4,• n_i. iY 142jr(/?l&a(
1
New 0 Renovation ❑ Replacement D " Plan Submitted: Yes
— 0 No 0
FIXTURES •
s'i ` RECEIVED
v � •
Z
(`I z -, MAYO 2011
o k rob ay n .
eF ?
�
z H v < ill
I- U t4 ao z z ° ,-
eUILOIN DEPT
< e' <y ' N a r < y X0 <Uu u < ui6 < wc. a < zaa
8 LT
m F. V. rgn 0n ;-14 E5 te it
CF << < O = jNz 8 o .., z .. .v1 oU
3 ad m H c N o < O < tiJ pw, < a C 3 O m< o
SUB-BSMT
•
1.
BASEMENT 1 - . I- .
' � YT FLOOR
• nno FLOOR •
• • re .
3RD FLOOR . •
,
.... 4TH FLOOR .. ..• .
5TH FLOOR - -
•
. , 6TH FLOOR ' • -
}, • -
`` �rx FLOOR , _ .. .. . .. .
ir •
St"'11 OO:: • ...
•
•
• r: Installing Company Name ,Al► •i 0,10 ,.,'2 s Pi : s Check one: Certificate
•
y fr rporation ,.S.953-
.S�r.'
Address_ Uy1 {Qi� >{rf�
. '( nr , (na, gnLj • 0 Partnership
BusinessTelephone I �9- mg-mot ❑ Firm/Co.
f •
Name of Licensed Plumber —3'?5 EIa)k I bn $ra
.
INSURANCE COVERAGE:
I have a current lisa.bitily insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. .
Yestr No 0
If you have checked VCs•please indica a type coverage by checking the appropriate box.
A liability.insurance policy Other type of indemnity 0 Bond 0
- O WNER'S'INSUR:4t<eE-wxIVER'''tam-aware-that-thciieensee-Joes•norhxve 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 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 arc 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
th ..+mi chusetts Stat•p,t bin Code and Chapter 142 of the G
By k40104rJ51
y, ,['�,,, Sign,/-it of is nsed Plumber
Title (N STIC{Wt.,
\ • pe of License:Master D� Journeyman O
; .;. t,, 'APPROVED(OFFICE U ONLY) License Number• / �-/qty"
r w', a