HomeMy WebLinkAboutG-14-1074 SN. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM OAS FITTING WORK
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CLEARLY NEW:UI f RENOVATION:9 REPLACEbENT:0 PLANS SUBMITTED: YES 9 NOBS
APPLIANCES 7 FLOORS-4 BSM 1 2 3 4 6 6 7 8 9 10 11 12 13 14
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I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 YES€1 No 0
IIF YOUR EqKEDYES,PLEASEDANCATETIETYPEOFCO EBYCHEgONGTHEAPPROPRIATEBOXBELOW • .
LIABILITY INSURANCE POLICY DIOTHER TYPE INDEMNITY 0 BOND 0 •
OWNER'S INSURANCE WAIVER:I am aware that the paras does not have the Insurance coverage required by Chapter 142 of the I
Massachusetts General Laws,and that my signature on this permit application pelves this requirement. I
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malSIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 1I AGENT 0 j
I hereby cerlay l or the creak and intimation 1 have aut nY0ed or entered swanky this applleallon we um and accurate N the test of my Imowledge II
and that all plunking work and Installations performed under the pen*Issued for VYsapplicator)wig be h cotnplW>ce W, PareneN pmvklan of the
Massachusetts State Plumbing Cade and Chapter 142 of the General taws
PLUMBER-GasFTrrERNAME hater £VQde 1LICENSE;ttWATO, s1.."aGNATURE
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