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~\`I' oF`""r--- APPLICATION FOR PERMIT TO DO PLUMBING
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Fee: $
PERMIT NO.rP I I — 71 se
/ Date t� '.1-20 1[
Building / ((� /� Owner's GfwoAt AzcjTdti
AT: Location /6 Si/ 6T I��L cT h Name
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Type of Occupancy lam'
New❑ Renovation ❑ Replacement'
Plans Submitted Yes❑ No❑
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SUB-BSMT.
BASEMENT i
- -
1ST FLOOR
2ND FLOOR
3RD FLOOR
(PRINT OR TYPE) Check One:
Installing Company Name CHECKOWPV ENTERPRISES ❑ Corp.
Address 11 SCARGO HILL ROAD ❑ Partnership
ULNNIS,MA U2W
508-3R5-1911
.11-.rirrfilierIPMfrt CHECKOWAt
Business Telephone Name of Licensed Plumber
INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent. Check One: Yes" No ❑
If you have checked YES, please indicate the type of 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 voerage required by Chapter 142 of
the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check on Owner ❑ Agent ❑
Signature ofOwner orOwner'sAgent
I hereby certify that all of the details and information I have submitted Sig a of Licensed
(or entered) in above application are true and accurate to the best of Plumber
my knowledge and that all plumbing work and Installations performed
under Permit issued for this application will be in compliance with all l Y�j7
pertinent provisions of the Massachusetts State Plumbing Code and License Number
Chapter 142 of the General Laws. Type: Master Journeyman 0