P-11-232 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
_'.I(_yr City/Town: MA. Date: U—Z
Permit# —232
Building Location:/75.-- eiragSdn4-, rs1
Owners Name: / 14
_
P Type of Occupancy: Commercial❑ Educational Institutional❑ Residential
n Replacement:IndustrialPla Ye
❑
New: � Alteration: Renovation: p
Plans Submitted: Yes n No
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T Check One Only Certificate#
Installing Company Name: 5 F//I//Ns(OGV 1 ..sive
,v IN Corporation /Las
Address:2/ g,f?O.V 6/PO. , City/Town: el.(� yAr2/710077f State: MA
0 Partnership
Business Tel: 509-3 QV-7775 Fax: SOS SQSA' 8aS6
0 Firm/Company
Name of Licensed Plumber: 5, P, W2EVSLOk),217::.
INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 Yes,No 0
If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. •
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
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 Owner's Agent
I hereby certify that all of the details and Infomratlon I have submitted(or enters rega.. •- is application are . and accurate to the best of my
Knowledge and that all plumbing work and Installations performed under the rmit I ed f,r th applicatt ,o •e In compliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 1 2 oft Gen I -wa.
3y Type of License:
nae 0 Plumber Signature of Licensed Plumber
;ity/Town ❑ Master❑,lourneyman License Number: ,2939
I
1PPROVED(OFFICE USE ONLY)