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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type)
r / Ma Date // -O7 Sr' 1 Permit# ?12^,-S1
�;, _ ...4...4 :_ ft Buil�g Location /(v dr{/S• /TOMS, Owners Name tri' r/ t Ai a!?/i�
'k ''Z) ES 7 77-7 - 7 r Type of ccupancy S
ri = New ❑ Renovation Cl Replacement ll Plans Submitted: Yes ❑ No i�
FIXTURES
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SUB-BSMT. I., r
BASEMENT f I t C c jj LS I ;11
1ST FLOOR
' 2ND FLOOR iiv 0 t .0 1 J
3RD FLOOR
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4TH FLOOR -
5TH FLOOR
6TH FLOOR
7TH FLOOR
' 8TH FLOOR
. I p� n Sack one: ^C'�ertific e,�
Installing Company Name/7T�, Ga/2S/040 / 4-C O. Corporation S gf ("
Address B ?PC)rc/cin €&i 1-71,M. / ❑ Partnership
• Z- ycl.en-�Uyuh /77a ozc(o� ❑ Firm/Co.
Business Telephone Ariel' ' 394- 7778 •
Name of Licensed Plumber
INSURANCE COVERAGE:
I have a curve liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No❑
If you have checked yes, ple,pb indicate the type coverage by checking the appropriate box.
A liability insurance policy qY 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.
• Ch k one:
Signature of Owner or Owner's Agent Ow - l Agen
I hereby certify that all of the details and Information I have submitte or entered)9abov: app •tion are t a . accurate to
the best of my knowledge and that all plumbing work and Installatio performed nder a pe it is ed fo . application will
be in compliance with all pertinent provisions of the Massachusetts Sta 11n1SbT Code an. :p =r 142 . e General Laws.
By C
Title Signature of icensed Plumber/
City/Town Type of License: Master GY Joumeyman ❑
APPROVED (OFFICE USE ONLY) License Number /,,17-115