HomeMy WebLinkAboutG-14-802 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO
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CITY: ii NTP. ���DATE �JOSSITEADDP,ESS: P)96C1 ! tiav✓NER'S NAME 7
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UTLPE OR OCCUPANCY YP • COMMERCIAL❑ EDUCATIONAL 0 RESIDED IAL
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O fd. CLEARLY NEIN: RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
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1 INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES NO ❑
If you have checked YE,please indicate the type of coverage b ecking the appropriate box below.
• LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAVER: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 AGENT
hereby c=..rfny that all of the details and information I have submitted(or entered)regarding this application are tue and• Rite to the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this application will be V, pliance wdh all Pertinent
provision of the Massachusetts State •umbin. Code and Chapter'142 of the General Laws. _
PLUMBER/GASI-I! !tit 1E L Li PIA A. iI / LICENSE#75-411
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COMPANY E ` 4�T r 4. ADDRESS: 75 �I � `-/�fJ>
CITY• � -11/ _-N� ' 4 7 ATOV STATE a ZIP: � FAX:
TEL: _ it! _ , r e s es EMAIL: •
MASTERS OURNEYh4AN0 I..l� IST^LEER❑ CORPaRAT10N C:1-4 qA4g,sffzef E D LC o g
FEB 2 4 2014 4/
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TIOSPAGE FOR INSPECTOR USE ONLY "MAL INSPECTION NOTES
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THIS APPLICATION SERVES AS TIIE PERMIT ❑ 0
FEE: $ PERMIT I _
FLAN REVIEW NOTES
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