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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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_;;(;(_ City/Town: Y/i2n to✓1-ft• MA. Date: (e— 13 o// Permit# I-70 7
Building Location: /4-1? B r u e flock IV Owners Name:5T9 3 I V �C r u ? C r U S
PType of Occupancy: Commercial❑ Educational❑ Industrial O Institutional Q Residential
O New:❑ Alteration:0 Renovation:❑ Replacement: Plans Submitted: Yes❑ No❑
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BASEMENT / "
In FLOOR
2N0 FLOOR
3R0 FLOOR
4114 FLOOR
5TH FLOOR
6TH FLOOR
Tn.FLOOR
el FLOOR
/ Check One Only Certificate#
Installing Company Name: 7'/{ r)r✓ �oy k- P C 14 Zw a
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0-Corporation c-• L?js�1
Address:P.O R d-er (fl oo City/Town: HyAa.'tt.4 uest State: 01l.72-
❑Partnership
Business Tel:(05j ' 77C 13 sr Fax: 0 Firm/Company
Name of licensed Plumber: F2.4/„e, S ' tsy(fie
INSURANCE COVERAGE:
I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch. 142 Yes 0 No 0
If you have checked Its.,please indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy Q— Other type of Indemnity ❑ Bond 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
Check One Only
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and Information I have submitted(or entered)regarding this application are true and accurate to the best of my
Knowledge and that all plumbing work and Installations performed under the permit issued for this application will be In compliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By Type of Llcense:C^ '
Title 0 Plumber Signature of Lice . • • i• • / e•
Clty/Town 'Master
APPROVED(OFFICE USE ONLYJ_ ❑Joumeyman License Number: 9-0