HomeMy WebLinkAboutPlumbing Permit ,""oF y,-:: APPLICATION FOR PERMIT TO DO PLUMBING
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(OFFICE USE ONLY)
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PERMIT NO. 04}- r' 1c�,.
HEfLTH DEPT.
Date S 110 20 0
Building .>9 >� c7-0,,) r`ck Owner's
AT: Location Name
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ii Type of Occupancy >Z--e..S
New❑ Renovation t- Replacement❑
Plans Submitted Yes❑ No❑
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SUB-BSMT. _
BASEMENT 1
1ST FLOOR
2ND FLOOR
3RD FLOOR
(PRINT OR TYPE) Check One:
Installing Company Name ,A td e /)/-e c G--it-S f r Iv is r4.1 S ❑ Corp.
Address I T 5 •'11 1.7-4 S T ❑ Partnership
pc 01 r S P 0 IN 7— . ,i 4- 002-635 5e. Firm/Company
Business Telephone ge, 1 - 73‘ I Name of Licensed Plumber 'p - CC/AZgc.
INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent. Check One: Yess7 No ❑
If you have checked YES, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance voerage required by Chapter 142 of
the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check on Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
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I hereby certify that all of the details and information I have submitted gnature of icensed
(or entered) in above application are true and accurate to the best of Plumber
my knowledge and that all plumbing work and installations performed
under Permit issued for this application will be in compliance with all ( C) 302
pertinent provisions of the Massachusetts State Plumbing Code and License Number
Chapter 142 of the General Laws.
Type: Mastery# Journeyman El