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----MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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=;{y{_ City/Town: �IIiLOri °�/�/�� / MA. Date: 3�/ // Perm/it#1"I I 53�
Building Location: W Sl2 1 7 6 4- Owners Name: C9-lh 0 u iv'
PType of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential ED
d New:❑ Alteration: Renovation:❑ Replacement:❑ 'Plans Submitted: Yes No❑ _
' IMFIXTURES
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SUB BSMT.
BASEMENT
1ST FLOOR a / / a /
2ND FLOOR / Ca. I
3"a FLOOR
("FLOOR
5T"FLOOR
5T"FLOOR
7T"FLOOR
BT"FLOOR
" i� /- Check One Only Certificate#
Installing Company Name: f-' DA—DS / !ui,417!'
/l /j - / ,V M��L Corporation
Address:Pei Ao.X )0/9— City/Town: ?✓t u42/✓ r State: 1 4
Vii,
0 Partnership
91
Business Tel: ?(D 7 /.3!1 p S'Fax: 36'3.-- p273 . 0 Firm/Company
Name of Licensed Plumber. "67(/ Wa'a,4
INSURANCE COVERAGE:
I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 Yes No❑
if you have checked Yes•please Indica a type of coverage by checking the appropriate box below.
A liability insurance policy Other type of indemnity 0 Bond ❑
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 ❑ Agent 0
Signature of Owner or Owner's 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 plumbing work and Installations performed under the permit issued for this application will be in compliance with all
Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. •
Be +W&X1// Type of License: e :1,e
Title I LIS' 'rc4 1-4....J 0 Plumber Signature of Licensed Plumberlu
CIry/Town YAFFICE ON oumeyman 0 Master
License Number: �f O 0 /
APPROV (OFFICE USE ONLY)