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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type)
(X,rr- k Fbe_ Mass. Date CPA II Wj(( Permit# PIS" Z
1 =_''�"' it- p B ildG ing Location'22- 7/ LuC C( Owner's Name W E zE(i
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' t Type of Occupancy laliS f 10E-
-LI: New 0 Rendvation ❑ Replaceme t Plans Submitted: Yes ❑ No R
FIXTURE
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SUB-BSMT. X r-- 1 i'. i:t
BASEMENT '`
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1ST FLOOR i' ^. 1 3 'L'
2ND FLOOR \ t }`T '+
3RD FLOOR
4TH FLOOR �! '
5TH FLOOR
6TH FLOOR
7TH FLOOR
• 8TH FLOOR
l `/' Sack one: ^C�ertific e,+
Installing Company Namely iaJ2S/ndi 41-do. Corporation -3 8/ ("
Address g Kea r 0/1 (',r / .. ❑ Partnership
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S' Ycr,ernciiV inn_ OZWoV ❑ Arm/Co.
Business Telephone sag - S94- 7776 ACCEPTED 4.____
Name of Licensed Plumber BTy
INSURANCE COVERAGE:
I have a curre liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
YestZ 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.
Chq 'k one:
Signature of Owner or Owner's Agent Owner rd Agent ❑
I hereby certify that all of the details and information I have submitt:• • entero. in abov plica'on are t .e and accurate to
the best of my knowledge and that all plumbing work and install.g ons perform'(under a rmi ssued .r is application will
be in compliance with all pertinent provisions of the Massachusetts a : - ging Code a pter 1, • .e General Laws.
By
Title Signature of Licensed Plumber/
City/Town Type of License: Master �' Journeyman ❑
APPROVED (OFFICE USE ONLY) License Number /7j' -i