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� MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBINGcO
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• Y\ (print or Type)
j„ `1 ass. Date �Z 1_S I ��2Q—Permit#11 Z
19_ �c d6wner's N•
ame \
i- ._ Building Location is
Type of Occupancy �J
Owner Tell ^^^^
lacemen tom' Plan Submitted: Yes 0 No ❑
New 0 Renovation 0 Rep FIXTURES
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V1 , u H 0 y a,
F tcyn LI. Pa
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Pm 2
3 5 $ , x s o S `3 (3 N s i g li ! g ul 0
SI 1B-BSMT
BASEMENT
15Y FLOOR .
2ND FLOOR -
IND FLOOR '
4Th FLOOR
5,m FLOOR
•
6TH FT OOR •
7714 FLOOR
gTN FT OOR
Installing Company Nameae/ E �d,// And f22r, Check one: Certificate
/7f /1-14'it" „Eget74 Corporation
Address��gq1/144
,, A� L�
C ..f u/Z/Jn ri44 doZ& ❑ Partnership
Business Telephone k6() •gat &3&6 0 Firm/Co.
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 No 0
If you have checked m,please indicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity O Bond 0
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. Check one:
Owner 0 Agent 0
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the • it issued for this applicatio• will be in compliance with all pertinent provisions of
the Massachusetts State Plumbing Code and Chapter 142 0 • Ge ral Laws. /
B _ . . P �.
By
ignature of Licensed Plumber
Title
Type of License:Master Journeyman o
City/Town y h l��j/
APPROVED(OFFICE USE ONLY) License Number u(T-