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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Printo Ty•e) Z�j O�/ Permit#T�II '�s��
V s• P ILe �U�N , Mass. _pate -�� I I
,- •= �, Building Location �3/ 90J� 1 " ' W Owner's Name f^F�
.' • UN ' ZC Type of Occupancy CSI 5-E rrl !a�
II New ❑ Renovation ❑ Replacement Plans Submitted: Yes ❑ No ❑
FIXTURES / \
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SUB-BSMT.
BASEMENT - JL N O 7 701 D
1ST FLOOR . .
2ND FLOOR , cvlu t�t U[ar
3RD FLOOR —
4TH FLOOR
5TH FLOOR
6TH FLOOR
7TH FLOOR
8TH FLOOR
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ck one: � ale
Installing Company NamenmanS%Ocl�0 fii5` do. .3a
c S.-Corporation c // (
Address.Address g CPQ raven ri tee/4. ❑ Partnership
• •S)- YC/ •Jr7Ci i b /211A. UZ(c6 ci ❑ FI Co.
Business Telephone sne - 394- 7 776
Name of Licensed Plumber
INSURANCE COVERAGE:
I have a currepcliability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No CI
If you have checked yeplea indicate the type coverage by checking the appropriate box.
A liability Insurance policyOther type of Indemnity ❑ Bond CI
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.
C��ff kk one:
Signature of Owner or Owner's Agent
Owner Agent ❑
I hereby certify that all of the details and Information I have submitted eyed)in bove ap•-icatio :re tr#00ue , • accurate to
the best of my knowledge and that all psionslo9the Massachusinstallations
etts State erformed u ode andthe s (((,is Zf•or a eneralapplicatLawion sill
bei. • •'Dance with pertinent p�
Byr!.f!!!<ta e.��!� ( /
Title Ir 'sPTc ' ( Signature of L' ensedPlumber/
City/Town , 0 Type of License: Master G3' Journeyman ❑
APPROVED (OFFICE USE ONLY) License Number /,7-,Al "}