PP-696 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
DFt-2T&t ouT H-
, Mass.( Type of Occupancy-COMMERCIAL 0 RESIDENTIAL( `�/ 1° � 0
Owners Name)) c, P � Owners Address 90 '/ Y N o- V ' R
Building�ng Location q Rx IrKAA t Date 3 - `t - 9 c�
New L- Renovation ❑ Renla ement 0 Plans Submitted n �� P_,xg,
.,_.fite,
‘,-74-11y--= , iiii ;11111: 111 / 1gliMila4
hibdiidhhiI1I
P Sus-asp.
BASEMENT
1st FIIOR I I 1 / I
•
2nd FIi00R a. 1 1 I
3rd FLDOR
4th FLOOR
5th FIDOR
6th FLOOR
8th FLOOR
8th FLOOR .
'O� rit( Installing Company Namee,cc PieV E/1-U I� r14 Check One: Certificate
\\ Address 3 4_ 14 t I-1-LA-14u0 A'✓t Corp.
CityLi I T -2 Coi iiI 'State fe l Zip Code 0 d-F3 ) 0 Partner
Business Telephone: 6/6 I) Ca 3- d- i 6 3 ❑ Firm/Co. t/
Name of Licensed Plumber or Gasfitter Ric an- R Q R N , 40(
INSURANCE COVERAGE: ante :
I have a current liability insurance policy or its substantial equivalent. Yes mN)❑
`'hj If you have decked yes, please indicate the type coverage by checking the wrtprriate boot.
1 A li\ ability insurance policy Other type of indemnity Bad
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
\l) Chapter 142 of the Lass. General Laws, and that my signature on this permit application 'awes this
regtll.rctent
Q One:
Owner t
Signature of Owner's Agent
I hereby certify that all of the details and infamatian I have submitted (or entered) in above application are true and
amxurate to the bet of my kneel-.19- and that all plumbing work and installations performed under tie permit issued for .
this application will he in compliance with all pertinent provisions of the Massahu_etts State Gas and chapter 142 of the
General Laws.
Title / ,,,,/.L ,l,Y,Le/of License: Signature e -�,r
�Y"' 7 E MAs1IIR "`�"�` Licensed Plwber
eleirtrag m 0 JOURN t N License Nether to 8 0 9'
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