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c14fi MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
?>•1IIII ' City/Town: )IRQM0,- -f,MA. Date: - /1- 11 Permit# 1 (Z -- t y l
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Building Locaton:LOR4<e.Fra fitrn O.1r.i;hssI�JgAOwnersName: n1R CIA- S,rcy
Type of Occupancy: Commercial 0 Educational 0 Industrial❑ Institutional❑ Residential[13- ---11
tc2 New:0 Alteration:❑ Renovation:0 Replacement: Plans Submitted: Yes❑ No❑
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1ST FLOOR •
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7TH FLOOR
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Installing Company Name:
R)C M 9SeIFC PI.-rn t f Y 4 r f111141 n‘
Check One Only Certificate#
r'ew ❑Corporation
3L{ COBIPri Is-AY Address: y City/Town: irletc State: MA
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0 Partnership
Business Tei�SDc'et%•743S Fax: � `
0 Firmit;ompan
Name of Licensed Plumber: Rt ell ARO Set Pe.
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 In,please Indica a the type of coverage by checking the appropriate box below.
A liability Insurance policy (1 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement
Check One Only
Owner 0 Agent El
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 pemut 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 License: a,
Title ❑Plumber Signature of Lice ed lumber
agaster City/Town a
APPROVED(OFFICE USE ONLY) oumeyman License Number. JPI• I C 631
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