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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Printstst or Type)
ta 1 trio(fih , Mass. Date CS'/7–// 19 Permit#r�t� a
p ' 'S '-�° •1 BuildingLocation /S'/IoS,t l y / 0511 / a"
�/J Owner's Name
: +.417- ,SOB X398– 1470 Type of Occupancy Zr's
j . New ❑ Renovation ❑ Replacement Plans Submitted: Yes ❑ No
FIXTURES
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SUB-BSMT.
BASEMENT
RECEIVED
1ST FLOOR
2ND FLOOR Iv AF 16 2011
3RD FLOOR
4TH FLOOR BUi_Dir c LEP
5TH FLOOR n
6TH FLOOR
7TH FLOOR
8TH FLOOR
y� /� Cck one: Certificate
Installing Company Name ilk-, tansI Odd >!5•"LO. iCorporation .302 / ["
Address e3 g&Q rC/0/) rj I'C 14. ❑ Partnership
• Z- YCf.e,n W0 in& OVic ❑ Firm/Co.
Business Telephone ST379 - .394' 7778
Name of Licensed Plumber
INSURANCE COVERAGE:
I have a curre liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes VI No❑
If you have checked yes, plea indicate the type coverage by checking the appropriate box.
A liability insurance policy 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.
Che k one:
Signature of Owner or Owner's Agent Owner rd Agent ❑
I hereby certify that all of the details and Information I have submitted(or entered) In above application :re true an...ccurate to
the best of my knowledge and that all plumbing work and installation e orm nder the pe.• it is ed for thi`..plication will
be in compliance with all pertinent provisions of the Massachusetts St Plumbin ode •• • :p r 142 of ty: eneral Laws.
By "
Title Signature of Ll ensed Plumber
City/Town Type of License: Master Journeyman ❑
APPROVED (OFFICE USE ONLY) License Number /.%-71