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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Pr nt or Type) 1-o 0
j�arIrv) ( Ah Mass. Date 97--/ 1s P rmit#'1t 2 -d
r Building Location S A/-I Yrl �. Owner's Name �
- ral : M r-rwit 1-/- ,0 Type of Occupancy P95
It
- New ❑ Renovation ❑ Replacement bpPlans Submitted: Yes CINo
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FIXTURES 577362. 5727
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SUB-BSMT.
BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR
5TH FLOOR
6TH FLOOR
7TH FLOOR
• 8TH FLOOR
n/� Cck one: Certific e
Installing Company Name e tansII Oddi r C O. Corporation _Fpst�
Address. Kea rc%n C/rl'_/4. 0 Partnership
• .'- Ye?•ei 7Cialth /79eA_ OZ(do c ❑ Firm/Co.
Business Telephone .snip 7778
Name of Licensed Plumber
INSURANCE COVERAGE:
I have a curve liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes el No❑
If you have checked yes, plea Indicate the type coverage by checking the appropriate box.
A liability insurance policy qY 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.
• COk one:
Signature of Owner or Owners Agent Owner Ag-• 11
I hereby certify that all of the details and information I have submitted(or ,• - >= abov: a.plica'•n are e a • accurate to
the best of my knowledge and that all plumbing work and Installatlo •erformed un--er the p.rmit sued •r thl application will
be In compliance with all pertinent provisions of the Massachusetts S • •lumbi:.r ode a . ' h:*ter 14•of e General Laws.
By
Title Sig • re of Licensed Plumber
City/Town Type of License: Master Gd' Journeyman ❑
APPROVED (OFFICE USE ONLY) License Number i4,17-16