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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
A tt Fri --,'i , Mass. Date dk� ?CI( 1I IPermit#P11-43(0
,. .---i. . .-: 4 building LocatiortZ - Lj Owner's Name BU L44 i '
--. :: Type of Occupancy 1 (1:i
. - New ❑ Renovation ❑ Replacement( Plans Submitted: Yes ❑ NoA
FIXTURES
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SUB-BSMT.
BASEMENT XC
1ST FLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR
5TH FLOOR
6TH FLOOR
7TH FLOOR
8TH FLOOR
PS
/� C ck one: Certificate�+
Installing Company Name�ril-rtan75I 60 P ribY C.O. ®"Corporation --�, 5/ [
Address a ?&?re on ('l re_/&.... / / ❑ Partnership
*SI' Yogi-ir ((/lh �Gl 0zCkV ❑ Firm/Co. •
Business Telephone Sr)54 - -I94- 7776 pCCEPIED
Name of Licensed Plumber
INSURANCE COVERAGE:
I have a curre liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes WI No0
If you have checked yes, plea Indicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of Indemnity 0 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.
Ch k one:
Signature of Owner or Owner's Agent 7 Owner Agent •
I hereby certify that all of the details and information I have submitt:• (or entery In above licatio are true - • :ccurate to
the best of my knowledge and that all plumbing work and installations p: . : under the rm' I ued for t - ..plication will
be in compliance with all pertinent provisions of the Massachusetts Sta : u. • • •de a C e 142 oft,. e: e al Laws. '
By
Title Signature of Licensed Plumber
City/Town Type of License: Master Gd' Journeyman ❑
APPROVED (OFFICE USE ONLY) License Number /,j'�,