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MASSACHUSETTS UNIFORM APPLICATION FO PERMIT TO DO PLUMBING
d_i- S City/Town: V ,,,(MA. Date: Perm //S(p
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Building Locatio:7a in 5 k n (< r� Owners Name: Ree Vl Ary' S 1‘M nil°I1,
PType of Occupancy: Commercial❑ Educational❑ Industrial El Institutional❑ Resldentialtg,
New:❑ Alteration:❑ Renovation:V] Replacement:0 Plans Submitted: Yes 0 No❑
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BASEMENT '
1ST FLOOR I I '
2"FLOOR
Sao FLOOR
4TH FLOOR '
5Ta FLOOR
6Ta FLOOR
7Ts FLOOR
ST"FLOOR
�a I/e_ ern e flUm W-e Check One Only Certificate#
Installing Company Name: W
U 8�X
Address: 35:2 Cky/Town:3:1'0tu# M //A0 Corporation
ID Partnership
�State: 1=1 '
Business Tel:538 31 `' 3283
Fax: M n Firm/Company
Name of Licensed Plumber: I.l.Ja V t d 1 'C 1 (`D-S s t n
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes 0 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
Owner 0 Agent ❑
Signature of Owner or Owners 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 plumbin work and Installations performed under
`the
permit Issued for this application will be In compliance with all
e ent prov n of the Mas setts
sSState Plumbing Code and Cha 7422yof the General Laws.
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TheLiep�p�� 1 fie of License: at 1 lR
Title l06-eT ` , _ ElPlumber Signature of Licensed Plumber
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License Number: l 6 q t
APPROVED(OFFICE USI"ONLn •urneyman