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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Pdnt or Type) Zoe/
�_► ffi'c,r,cniWm , Mass. Date /11 20 !8 Permft# 1)17' —2°4
. Building Location''/20 lend rd thy Owner's Name 90 11
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E' `? J775'2BEC—LL1, /Armco,l�l-� Type ofpccupancy / fi S /
New ❑ Renovation ❑ Replacement r3" Plans Submitted: Yes ❑ No 19"
FIXTURES
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SUB-BSMT.
BASEMENT t
1ST FLOOR
2ND FLOOR ,.
3RD FLOOR
4TH FLOOR
5TH FLOOR
6TH FLOOR
7TH FLOOR
8TH FLOOR
Cck one: Certificaje
Installing Company Namefri, ia12S/Ocil tfY �O. ®'Corporation _?ag/ (-
Address a KPCT r abi7 C.'nz/&. ❑ Partnership
• Z- Ye/l -177( e lb /flex_ 024 c ❑ Firm/Co.
Business Telephone SZDM- 395z' 7778
Name of Licensed Plumber
INSURANCE COVERAGE:
I have a curreptliability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes CI No CI
If you have checked yes, plr 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.
• Chek one:
Signature of Owner or Owner's Agent Owner GGd' At-nt ❑
I hereby certify that all of the details and information I have submitted in boy: plication ar, and accurate to
the best of my knowledge and that all plumbing work and Installatio erformed u r t : •e i Issued . is application will
be in compliance with all pertinent provisions of the Massachusetts State In ode a • •h pter 14 . the eneral Laws.
By C
Title Signature of Licensed Plumber/
City/Town Type of License: Master Gd' Journeyman ❑
APPROVED (OFFICE USE ONLY) License Number / z98