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' MASSACNUSETTS UNIF(3RM APPLICATION F�R PERMIT T0� DO PLUMB�NG
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('7 �,,,. _�(�f�r/�f , Mass. Oate r��7 .-�-QS Permit #�Fb � l� Z..
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� �� Type of Occupancy �C.%4
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� New ❑ Renovation ❑ Replacement � P1ans Submit;e�: Yes 0 No C
' FIXTURES
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lnstaliing Company Name A & B Canco
Check one: Certificate
Address 350 Main Street � Ccrporation 2305
'�e� Yarmouth, MA 02673 � Partnership
Business Telephane 508-"775-2800 �� p F��fCo.
Name of �icensec: Plumber pouQ Lancttrv w�
itVSLJAANCE COV�RAGE:
1 have a curr�t iiability insurance policy or its substantial equivalent which meets the requirements of MG� �'h. 142.
Yes �: No �
If you have checiced,yes, p�ease indicate the type coveragc by checfcing the appropriate box.
A liabii'�r insurance poGc
Y � Other type of indemnity ❑ ga�q �
OWNER'S INSURANCE WAtVER: ( am aware that the licensee does r
Ghapter 142 af the Mass. Generat l.aws, and that my signature on this perrs�t applicat on wa ves this egui ement�Y
Check one:
Signature cf Owner ar pwner's Agent Owne� ❑ Agent[]
1 hereby certify that ail of the deiails and information f have submitted (or entered)in above application are true and accurate to the Gesi el mv
knowledge and that a(1 plumbing work and installations petormect under the permii issued for this appiication wiH be in compliance+�ith al! �
pertinent provisiens af the Massachusetts$iate Ptumbing Cade an Ct�apter 42 of the General l.aws.
8y
Tii1e icn �t er
City/Tcwn �Ype of Ucerse: Master�'�, Journeyman ['j
A�'PRO�E !O iC U c QNLY) ticense Number 1 1 3 0 5