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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING S�r,10d .1,Z7<
=41-3 City/Town: kY/Y)0/4) ,MA. Dated 7-V-/ Permit# (3 r Q
Building Location:/S .5thn/Qch di/ /L! Owners Name:MC91 h , Gl/eL
PType of Occupancy: Commercial 0 Educational❑ Industrial 0 Institutional 0 Residential a
New:❑ Alteration:❑ Renovation:0 Replacement:Er Plans Submitted: Yes 0 No 13/
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r/ /� Check One Only Certificate#
Installing Com any Name: I'"d I/I n Sk 1� al `� G
(y J //r1 (� �� IllCorporation
Address:/ 6Pall /1n fir City/Town.0 %?/yieinl State: N/G'L— 0 Partnership _ •
Business Tel:40ri a�/777f Fax:/]] � /A , n I // _
Name of Licensed Plumber: a.apip rj /-/— S�/J GAJ !C, / `
INSURANCE COVERAGE:
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I have a current liability Insurance policy or Its substantial equivalent which meets tl ern No❑
If you have checked Yes,pleasel
Indicate the type of coverage by checking the approl f r
A liability Insurance policy Other type of indemnity ❑ . //
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the InsuY G r 142 of the
Massachusetts General Laws,and that my signature on this permit application waive
Chec ne Only
• • 'r ❑ Agent
Signature of Owner or Owner's Agent
I hereby certify that all of the details and Information I have submitted(or tared)regarding this ap loot] are true a•d ace rate to the best of my
Knowledge and that all plumbing work and installations performed under th, •- • Issued for th appll tion will be n co, pliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the : alai s.
By Type of License:
Title 0 Plumber , • ° o Licensed Plumber
City/Town 0 Master /
APPROVED(OFFICE USE ONLY) ❑Journeyman License Number: /
•
FINAL INSPECTION BELOW FOR OFFICE USE ONLY - PROGRESS INSPECTION(S)
FEE: S PERMIT II
APPLICATION FOR PERMIT TO JIO PLUMBING
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LICENSE NUMBER:
PERMIT GRANTED 9 DATE: -
PLUMBING INSPECTIOR , '
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