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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
ii -ki_3liV� Cty/Town: ywin1lhT7f MA. Date: ' /4/' PermitN(-77 2--
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Building Location: / -BID/—ILO
nI /JILO UKLbe- Owners Name: ,LEDLIAC.rfrZo7a /A.w
PType of Occupancy: Commercial] Educational❑ Industrial❑ Institutional❑ Residential❑
New:❑ Alteration:n Renovation:❑ Replacement:[ Plans Submitted: Yes❑ No❑
FIXTURES
RECEIV EEr yDICATED
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C u- 1'• 3 NO C 3 = Z I-- LL ` S Y Q E W W W 1 1' YQ
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40000 LL s x 5 5 a: v� ,m I- g 3 3 3 o Q c9 a C
SUB BSMT.
BASEMENT � -
isT FLOOR
2Ne FLOOR
3"e FLOOR •
4T"FLOOR
5TH FLOOR
6111 FLOOR
STH FLOOR
STH FLOOR -
Check One Only Certificate#
Installing Company Name: .L7/-14///YS/Dw, me. . Sn Corporation Qti e
Address:pp p Ai2D0de/ie. city/Town: c YtV&W/state: r"lj4,
0 Partnership
Business Ten-. '9s$797? Fax: ,h02-3991 f07.4-‘ ❑Finn/Company
Name of Licensed Plumber: - TS/W E4/ A. if,/,,ysawA>
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 indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy V 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 Owners Agent
I hereby certify that all of the details and information I have submitted(or entered r . • is appl tion e true an• urate to the best of my
Knowledge and that all plumbi' work and Installations performed under the - it issued toy i .p. Ieatl'
• will be •mpllance with all
Pe. ent provis - •ff the Mn usetts State Plumbing Code and Chapter 1• • - - e` Laws. /
By '►_._ '..esi !.�—J Type of License: - /
Title I NSflelate- r Plumber Signature of Licensed Plumber •
��• D e Master
CCity/Townt ❑journeyman License Number: /a 2 98
APPROVED(OFFICE USE ONLY)