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HomeMy WebLinkAboutP-01-277P� ^fti APPLICATION FOR PERMIT TO DO PLUMBING (OFFICE USE NOV 0 2 Z000 UU U Fee: $ RO. (n� O BY PERMIT NO. \ Ol ^ 117 6 /e E7 v/u-?) Date O 3 4V &V ©eZql-) Building Owner's AT: Location / i Name Z,u , MeM&UzW Type of Occupancy UAAE .,IAN6 New ❑ R{enovationXi Replacement ❑ Plans Submitted Yes ❑ No ❑ z Z rA y to O V N Y > N W ul . to J coQ M ¢ S~ Q V) Z O Z Z 2uj a CC z CC w a D w a vW) 0 a w y Z o oa_- o a LL tr-j Z LL Q F> H O y 0. y 7 y !- Z O O U7 Z W H O D S �i Y J J �i H y LL m VJ C G S a O G Q 2 m O SUB-BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR O Oo (PRINT OR TYPE) 1r Check One: — C A ] 137 Installing Company Name E,F�1mLa L) )q 9r, Corp. DIX—AN(won Address [S ,/3-jPA�A�jf�P. ❑ Partnership , y�/�L7TT/i�' / �� �6�/ � ❑ Firm/Company Business Telephone M 37T'77-79 Name of Licensed Plumber le c w/NsLIJu) 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 ofOwnerorOwner'sAgent 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 ❑ Acent ❑ SignaTu—re of Licensed Plumber 7939 /&-as 692oeam License Number t Type: Master P Journeyman ❑ I