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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type)
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G Building Llocation( 4'/ncS' /°f JOwner's Name li it . Ce/ cJ
e-, Type of Occupancy f0'
New 0 Renovation 7 Replacement 0 Plans Submitted: Yes 0 No 0
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FIXTURES
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SUB-BS MT. .
BASEMENT
1ST FLOOR 2, 19 2- I I I I
2ND FLOOR
3RD FLOOR
4TH FLOOR
5TH FLOOR
8TH FLOOR ,
7TH FLOOR
8TH FLOOR -
Installing Company Name Seibold Plumbing & Heating, Inc. Check one: Certificate
Address 73 '
Carter Road El Corporation 1810
Worcester, MA 01609 0 Partnership
Business Telephone (508) 756-6461 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 El No ❑
If you have checked Yes. please indicate the type coverage by checking the appropriate box.
A liability insurance policy 50 Other type of Indemnity 0 Bond 0
t the
es
ot
OWNER'S
142 of the Mass.General Laws, andrthate amy signatures on othisnhave
permit application waivecoverage
this requirement.
by
Chapter
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 pplicat'on are true . d accurate to the best of my
knowledge and that all plumbing work and Installations p ed undo he permit -•issu or th''/.•pli ; • ll be in compliance with all,
pertinent provisions of the Massachusetts State Plumb a an a e of th./ener/i-f
Si nature of Licens Plumber
Title Type of License:Master] Journeyman 0
City/Town
APPROVED(OFFICE USE ONLY) license Number 10229
BELOW FOR OFFICE USE ONLY
•
FINAL INSPECTIONS SKETCHES PROGRESS INSPECTIONS
FEE
NO.
APPLICATION FOR PERMIT TO DO PLUMBING
NAME&TYPE OF BUILDING
LOCATION OF BUILDING
PLUMBER
PERMIT GRANTED
DATE
19
PLUMBING INSPECTOR SII