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MASSACHUSETTS UNIFORM A TION FOR PERMIT TO DO PLUMBING
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N = Building Location 3� RX - II ..• ., Ah er's Name Ch1 Ka rlin
•;•• Owner Tela 3�—vo�2m Q� Type of Occupancy jee'ai .
•
New 0 Renovation ❑ Replacement ir Plan Submitted: Yes 0 No 0
FIXTURES
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• ' SUB-BSMT ,
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BASEMENT /•
. - 1n FLOOR
- 2TM0 FLOOR
Sao FLOOR
• • ... 4T"FLOOR _ . •
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STM FLOOR•
T"FLOOR • •
- !"i:;*??.1 ' 7T"FLOOR i i . - .. . .
• St"FTono ..
• ry: Installing �
CompanyJName �4N e 1J°A V j iG11.'3 . Check one: Certificate
•
Address Idl I'I y 4e5 pa 44•N •• ITCorporation feeX S •
• 3.'(r MA._( 2c,c,q 0 Partnership
• Business Telephone N �?gg_C4o k ecu 143 -3�-5;•77 0 Firm/Co. ,
Name of Licensed Plumber zciepkileri cca. •
•
INSURANCE COVERAGE:
I have a current Iia 'ity insurance policy or its substantial equivalent which meets the requirements of MOL Ch. 142.
Yes No ❑
If you have checked yes.please indicate the type coverage by checking the appropriate box.
A liability insurance policy t3� Other type of indemnity ❑ Bond 0
- 'OWNER SiNSVRR4NCE-W:tl'VE-Ry I am aware-that-the-Fiernsee•dnes-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.
Cheek one:
• Owner 0 Agent 0
Signature of Owner or Owner's Agent
I hereby certify that all of the detailsand information I have submitted(or entered)in above application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for ' tion will be in compliance with all pertinent provisions of
the Massachusetts State Plumbing Code and Chapter 142 of the Gene- or
' Signatur• .f'tcensed Plumber •
Title +
• • r f License: Master 0//,,�1 Journeyman ❑
r:r;�.: City/Town is—1( _
:.: ;...
,ki'',,y.., '•APPROVED(OFFICE USE.ONLY) License Number
o.n .ans? .e.: : . .