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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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-:77-111i-N,, City/Town: V4-tMOlUf}f' ,MA. Date: 1 /l7 /IU Permit# 9 �`r2`'�
Building Location: /S-0 5F -V1k4J ASE Owners Name: in Okla- After(_
Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential
New:❑ Alteration:❑ Renovation:❑ Replacement: a---Plans Submitted: Yes❑ No❑
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i I j Check One Only Certificate# --
Installing Company Name: Aqua Services Plumbing and Heating LLC.
121 Corporation 3081
Address: 350 Main St. Unit A city/Town:West Yarmouth State: MA
0 Partnership
Business Tel: 774-470-1350 Fax: 774-470-1350
0 Firm/Company
Name of Licensed Plumber:
INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 Yes ® 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 ❑ 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 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.
By Type of License: riot
Title ❑ Plumber re oSignet a ed mber
1� Plu
City/Town ®Master License Number: 11305
APPROVED(OFFICE USE ONLY) ['Journeyman
FINAL INSPECTION BELOW FOR OFFICE SE ONLY PROGRESS INSPECTION(SI
FEE: S PERMIT II
APPLICATION FOR PE' I TO DO PLUMBING
NAM &TYPE I B I IN
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LOCATION OF BUILDING -SKETCH
PLUMBER
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LICENSE NUMBER:
PERMIT GRANTED❑ DATE•
PLUMBING INSPECTIOR
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