HomeMy WebLinkAboutPlumbing Permit �.!
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Fee:$ t��G�
, PERl�IT NO:
Date � GO Z. �
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Building ` - Owner's �D�I�I�t�E"�'Is�-
_ AT: Location v �l E 1C� Name
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TYPe of Occupancy
New CJ u Eiendvation❑ Reptaceme�t'�
Plans Submitted Yes O No❑
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�` SUB-BSMT.
BASEMENT
1 ST FLOOR
2ND FLOOR
3RD FLOOR
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� (PRINT OR TYPE) � ��. � � Ch�CIC Ol'3� ���� a
lnstafling Campany Name .1�ws.m�, ��P_CC'C� O Carp. Lii� `���- � � ���� _ ;
Address "� ��N�P, a f��.� _Q Partne�' .
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�j � FirrNCompany
Business Telephone "��4-� a,��Z> Name of Licensed Piumber
(NSURANCE COVERAGE: I have a current tiabiiity insurance policy or i#s substantial equivaient. Check One: Yes� No �
If you have checked YES, please indicate the rype of caverage by checking the apprapria#e bax.
A liabitity insurance policy❑ Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: i am aware#hat the licensee does not have the insurance voerage required by Chapter 142 of
the Mass. Genera�.�aws, and that my signature on this permit application waives this requirement.
Check on Owner ❑ Agent ❑
Signature ofOwnero�Owner'sAgent
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1 hereby certify that all of the detaiis and #nformation f haae subnr' �"`"�"'
or entered in above Si ature of Licensed
( ) app#ication are true and ac,curate to the best of Plumber
my knowledge and that aii plumbing mork and instatlations perto
under Permit issued for this appiication wiii be in compfiance wi#h at! j � � � '
pertinent provisions of the Massachusetts State Piumbing Code and License Number '
Chapter 142 of the General Laws. Type: Mas#er,� Joumeyman�
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