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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
E _IlrA=J l_ �l I 1
i=a City/Town: 1A-201rn MA. Date: { Z 3 74// Permit#
Building Location: `ll ant!- T aTC 4o4-1 Owners Name: E/heA/ "r<//e5n4/
PType of Occupancy: Commercial❑ Educational D Industrial❑ institutional El Residential[r
New:❑ Alteration:❑ Renovation:❑ Replacement:Er Plans submitted: Yes❑ No❑
FIXTURES
DEDICATED
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SUB BSMT.
BASEMENT I I
1n FLOOR
2"a FLOOR
3RD FLOOR
4r"FLOOR
STe FLOOR
6r"FLOOR
7Th FLOOR
8Th FLOOR r
Installing Company Name: a 4-it d[l.J t Cc & ,t„ Check One Only Certificate#
0 CorporationAddress:lir*w,re-rrsrce4•to City/Town: � rutit. State: WI
p'2L t/�� 0 Partnership
BusinessTel:Th Via Y382_ Fax: Sob y3o 72x3 Irm/Company
Name of licensed Plumber: 4✓ t-c i 2.+, /hC--'Z,✓C
INSURANCE COVERAGE: r,/
1 have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 Yes IJ No 0
if you have checked Yes please Indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy �"'"--- Other type of Indemnity 0 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
Signature of Owner or Owner's Agent Owner 0 Agent El
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
Pertinent provision of the Mas chusetts State Plumbing Code and Chapter 142 of the General Laws.
OIL
By; �` Type of License: e---pr,
Title l n?T i VVV Signature of Licensed Plumber
j El Dumber
City/Town aster
APPROV D(OFFICE USE ONLY) ❑Journeyman License Number. �z V Z