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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print r Type)
�tHernaj/ 7/04Mass. Date /2 -Di W20/J Permit#
it, Building Location • Owner's Name 42.40/7/1..S
• �' = VS— viiirrr ale) Type of Occupancy ISS •— gybe
U . New - .Renovation ❑ - Replacement Plans Submitted: Yes ❑ No G/
FIXTURES --
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SUB-BSMT.
BASEMENT /
1ST FLOOR.
2ND FLOOR /
3RD FLOOR
4TH FLOOR
5TH FLOOR _
I 6TH FLOOR
7TH FLOOR
8TH FLOOR
II �/' //�� Deck one: Certifi e
Installing Company Name kria11S/040 PiA C.D. Corporation - 5 a8 C
Address 6 Kea r e)", e,ter,/&. ❑ Partnership
• ''- Ye/.c r204/V!7 iYJa oZ(4 ❑ Firm/Co.
Business Telephone spEs - 94- 7778
Name of Licensed Plumber
INSURANCE COVERAGE:
I have acurrept liabilityopol❑icy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes
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.
• = k one:
Signature of Owner or Owner's Agent Ow -r r Ag: t ❑
I hereby certify that all of the details and Information I have sub • :d(or entered) I Ailfov, applic: ion are t• e and a rate to
the best of my knowledge and that all plumbing work and Installations p: • ed u r the perm Issued 1• this appf -don will
be In compliance with all pertinent provisions of the Massachusetts State Plu • e �ode and C •' er 142 ' the Ge':ral Law
By
Title Signature of Licensed Plumber
City/Town Type of License: Master r3 Journeyman ❑
APPROVED (OFFICE USE ONLY) License Number /,7-7--,-"/