HomeMy WebLinkAboutP-03-485TOWN OF YARJI MOUTH
2003
�.S 1
APPLICATION FOR PERMIT TO DO PLUMBING
(OFFICE USE ONLY)
By.
Fee: $
PERMIT NO.
Building > Owner's 42
AT: Location I?/ �������� Name
Type %J Occupancy �f
Replacement ❑
_03_
Date
NewK Renovation ❑
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SUB-BSMT.
BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR
(PRINT OR TYPE) ? j 'P
ff jj
Installing Company Name I I A f �' f
Address S- sT�� S �� c x! P
r /
Check One:
❑ Corp.
❑ Partnership
L�j r-f i S t 6" S 4'!�Ie7 ZI-R Company
.�as z� 0�6 %7�ber < s
Business Telephone % Name of Licensed Plumber � ' � ✓ �
INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent. Check One: Yes ❑ 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.
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted
(or entered) in above application are true and accurate to the best of
my knowledge and that all plumbing work and installations performed
under Permit issued for this application will be in compliance with all
pertinent provisions of the Massachusetts State Plumbing Code and
Chapter 142 of the General Laws.
Check on Owner ❑ Agent
1
Signature of Licensed
Plumber
7-ar36
License Number
Type: Master ❑ Journeyman4