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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
=_;j_) S City/Town: VV yO Yt n' MA. Date: a I 7' 201I Permit#
Building Location: 'l Clrcu 14- (2 d• W e$-I•- Owners Name: Wo f/ctr ; YVI Icha-e I•
PType of Occupancy: Commercial 0 Educational 0 Industrial 0 Institutional 0 Residential®.
New:❑ Alteration:❑ Renovation:❑ Replacement:®• Plans Submitted: Yes❑ No a
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BASEMENT I
1;TFLOOR I I) C -, ll II 1111
2ND FLOOR I p I! I
3°D FLOOR II FEBC 7 LO' I'll
4TH FLOOR l LU
STH FLOOR 4
6TH FLOOR _ I
7TH FLOOR ° — — — _, —
8TH FLOOR
I�N Check One Only Certificate#
Installing Company Name: JuG1c
0 Corporation
Address: 3q mamma" City/Town: $''t/orv" - State: ISA
0 Partnership
Business Tel: 3 9 q-a-9 as- Fax: Firm/Company
Name of Licensed Plumber: UG etc 1Ca Y1 C
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes I .No 0
If you have checked X .please indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy Dn. 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 0 Agent 0
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
Pe. •ant provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By • i•__.��I s ' —).►�_,S Type of License: 4./
Title , Is - . GS Plumber Signa • : of censed Plumber7TS'
Ciryrtown 1gYL1rio ❑Master Lice = Number: c9 !9' !J S' •
APPROVES(OFFICE USE ONLY) IJoumeyman