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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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-I . New ❑ . _. 'Renovaton ❑ Replacement'CI - Plans Submitted: ; Yes'❑' No ❑
FIXTURES
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SUB-BSMT. I r l n r �'L u
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BASEMENT ; , c C 2( 11
1ST FLOOR
2ND FLOOR r rn r; =1 T
'% h 3RD FLOOR By
It 4TH FLOOR .
5TH FLOOR
6TH FLOOR _ _ . _
7TH FLOOR
8TH FLOOR
..••••--% Idl[� t6 check one: 38 C+Certificate�
Installing Company Name ft.Arian7S/DZ dO. t Corporation c2
Address g gee?re/on ('/r7 14 ❑ Partnership
• •S)- Yet gir it /Y9G� U Z(e6 V ❑ FimVCo.
Business Telephone Snel ' .394' 7778
Name of Licensed Plumber
INSURANCE COVERAGE:
I have a currept liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes10 No❑
If you have checked yes, plea indicate the type coverage by checking the appropriate box.
A liability insurance policy ' Other type of Indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage
required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application
waives this requirement.
Chk one:
Signature of Owner or Owner's Agent Owner rr ' Agent ••
I hereby certify that all of the details and Information I have submitt •r entere• in ab• e :optic. on are fru: . • accurate to
the best of my knowledge and that all plumbing work and Install: ions performe• under h •e • issued fo application will
be In compliance with all pertinent provisions of the Massachusetts - : •I , ••ing Code : • •.pter 14 • e General Laws.
By I salt
Title Signature of Licensed Plumber
City/Town Type of License: Master Ga' at Journeyman ❑
• APPROVED (OFFICE USE ONLY) License Number SAM'S