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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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"4/I 24ZW(tt /g17 ll/ Permit#Pi 2"
s __� = City/Town: MA. Date:
Building Location: 47/ .51-111-1-1P—P- Pt-.,w�r erN
s ame: U/1 LEN Zug
PType of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential
New:❑ Alteration:❑ Renovation:❑ Replacement:[E, Plans Submitted: Yes❑ No❑
FIXTURES
DEDICATED
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SUB BSMT.
BASEMENT I
_2N2ND FLOOR A
FLOOR �.
3R0 FLOOR J
4Th FLOOR
STN FLOOR ,
6TN FLOOR
7114 FLOOR
3TH FLOOR
Check One Only Certificate#
Installing Company Name: .at-A711/2/1/S/6111. /Re, 322/ L9
�r //�� C C _ ,tmyc/� /��_ I Corporation
Address:a ICCAI�/JO/✓ ��• City/Town: !7//� i i State:
�7�/ �1 / 0 Partnership
Business Tern.371-7971 Fax: .622e-89c� c9,2g 0 Firm/Company
Name of Licensed Plumber: �,/ ygj//4Ejt/ 4. 1.444/stow _
INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 Yesy No 0
If you have checked Yesplease indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy y 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 0
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or enter 9)regarding this •pplic• ion ar. true and a urate t. he best of my
Knowledge and that all plumbing work and Installations performed under the p it Issued for this ap• catlo be inc• plian•- with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 0 • Gener ,ws. i
By Type of License: K
Title Plumber Signature of Licensed Plumber
City/Town Master License Number: /a 2 9 P
APPROVED(OFFICE USE ONLY) ❑.IOUmeyman