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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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City/Town: IMUU+ ,MA. Date: l I i Z I 1 11 Perna(2.' ZG
Building Location: So wills/14a. L./ Owners Name:teb+ 15 SLSw*i o11 sy
PType of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential
New:❑ Alteration:®. Renovation:❑ Replacement 0 Plans Submitted: Yes 0 No
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SUB 8SMT.
BASEMENT / /
10T FLOOR
2ND FLOOR
3"FLOOR
41"FLOOR
51"FLOOR
6T"FLOOR
7"FLOOR
BT"FLOOR '
/y Check One Only Certificate#
Installing Company Name: t tt atS 59./1.25
❑Corporation
Address: 12/2c 3 7o City/Town: YA,,Cwi OVTL pnc?State:Atit
0 Partnership
Business Tel: ,524-3 2 9eite Fax: ¼W1(I2-E 2 .29 Ls— 0 Finn/Company
Name of Licensed Plumber. diene?,./ S S,4(5
INSURANCE COVERAGE:
I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 Yes 0 No 0
if you have checked Yee ,please Indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy Other type of indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER:I am 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 waive;this requirement.
Check One Only
Owner 0 Agent '❑
Iggnature 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 of License:
•
Title 1$'Plumber Signature of Licensed Plumber
City/Town Fj-Master /0./7r
APPROVED(OFFICE USE ONLY)
['JourneymanLicense Number.