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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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(]— / \rjrnatiros .Mass. Date P3 20 1 Permit// -0ga
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Building Location I �rtertuvol lL1J, Owner's Name
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�''',••c . Owner TelN Type of Occupancy K{ t tra\ •
` New & Renovation ❑ Replacement 0 Plan Submitted: Yes 0 N n
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:IXTURES
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BASEMENT
In FLOOR
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. 2Xe FLOOR .
Sao FLOOR • _ _ .
aT"FLOOR .. '
• STM FLOOR - .
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6T"FLOOR ' -
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• ': Installing Company Name57.41',� 1.�Q{ Idifkiki3 Check one: Certificate
Address ,/ h`+Qxs ¶'B\ / rC poration 53 ( .' •
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• F^/ ma_ ` ��a/�Ci41 0 Partnership
• Business Telephone p 509- , l '6qO( 0 Firm/Co.
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Name of Licensed Plumber Spc� ra . •
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INSURANCE COVERAGE:
• I have i current IjAkitily insurance policy or its substantial equivalent which meets the requirements of MGL Clt. 142. '
Yes No ❑
If you have checked yes.please jndicat e type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity 0 Bond 0
-- 'OwNER'stNStTR.aNCB-witrVER,Earn awarethat-the-Iieensee-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.
Cheek one:
he 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 this application will be in compliance with all pertinent provisions of
the Massachusetts State Plumhine Code and Chapter 142 of the G
By ore
' Sign e of is nsed Plumber
Title \ //
. pe of License:Master tam Journeyman ❑
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• "". _CP APPROVED
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.` " �APPROYED OFFICE USE ONLY) License Number r "�
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