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MASSACHUSETTS UNIFORM APPU ON FOR PERMIT TO DO PLUMBING
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`W ." Ci own: N/� fn ,MA. Date:
-,.;%.4.11W ." City/Town: ('v" 9-1/ Permit#��� - 7�
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Building Location: 64" ��mp/}/l/GQtp Owners Name: f{&L
PType of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential
New:[x Alteration:2Renovation:❑ Replacement:0 Plans Submitted: Yes❑ No O
-1 FIXTURES
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Z SYSTEMS
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SUB BSMT.
BASEMENT
151 FLOOR / / / / / / /
2"a FLOOR
Spa FLOOR
4T”FLOOR
5T"FLOOR
6T"FLOOR
7T"FLOOR
3T"FLOOR
.�!! n i Check One Only Certificate#
CA
Installing Company Name: RI I-e `,ffiVN/CA'
0 Corporation
Address:/73Iii//emhoet 2ity/Town: &/4/n)Ji5tfnnate: /j-
n /1 0 Partnership
Business Tel:r SOF' Syr - go 6/ Fax: 0 Firm/Company
Name of Licensed Plumber:
INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 Yes 0 410 0
if you have checked in,please Indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy ❑— Other type of Indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER:lam 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 ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my
Knowledge and that all plumbing work and installations performed under the permit Issued for this application will be in compliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By Type f License: t LP
ThePlu ber SI to a of Licensed Plumber
Cm,? aster
APPROVED(OFFICE USE ONLY)
['Journeyman
Number. 9 ,