HomeMy WebLinkAboutBLDP-24-896 IMP,. Pme a 6e
,)' .„:„ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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JOBSITE ADDRESS "7 7 Gee,-l''fe-_ 2 OWNER'S NAME IV) Rt..:., •y�•-4'''e
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TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL 0
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CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NOD
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• • INSURANCE COVERAGE: -
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES®-NO Ej.
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY a OTHER TYPE OF INDEMNITY ® 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 ® AGENT Ell
SIGNATURE OF OWNER OR AGENT '
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the bast 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 provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME, - /'14 S-vn' 4�i'7 . J LICENSE#14 fed 4i SIGNATirre
MP®'' JPEl CORPORATIONS 333`7 IPARTNERSHIP01111111111 LLCO#
COMPANY NAME A/7/5 j/775 /? z/ ,: L ADDRESS //eki,467, ,,,,-
CITY' (.1,e/2•e„,_,9 ?, ISTATE I ;,p I ZIP I 27, -7;3 TEL , ._m"
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