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:��'�� �� � Fee: $ � S,J� ;
� �� PERMfT NO. ;
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Building '� (awner s �=f��'�
. Location ��—� � ���'��� Name
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�8`'� ' �` `+ '� Type of Occupancy �� �
APR 3 0 ZOOZ New� Renovatio� Rep�acement O
HEAt,TH DH�aI'�s ubmitted Yes O No,��'
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SUB-BSMT.
BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR
(PRINT OR TYPE) � Check One:
Instafling Company Name � �,j �..<� ���'-��#� �� �� � Corp.
Address 3��°, ��-�'�� �� � Partnership
` `� � � . `� �`� FirmlCompany
����=� � i �;�7� �� .�. .��..,���:
Business Telephone � -% / Name of Licensed Piumber ���� ``��'
INSURANCE COVERAGE: ( have a current liability insurance policy or its subs#antiat equivaient. Check O�e: Yes,,�No O
If you have checked YES, please indicate the type of coverage by checking the appropriate box.
A liability insurance polic��� Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: 1 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.
Check on Owner ❑ Agent ❑
Signature of Owner or Owner's Agent �
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I hereby certify that all of the details and informatian 1 have submitted � Signature of Licensed
(or entered) in above application are true and accurate to the best of Plumber
my knowledge and tfiat all plumbing work and installations performed �����
under Permit issued for tfiis application will be in compliance with alf
pertinent provisions of the Massachusetts State Plumbing Code and ' Licens Numb r
Chapter 142 of the General Laws. Type: Mast��� Journeyman❑