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ASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
_:)(- 4 City/Town: yH2ri007-H ,MA. Date: 9/291/0 Permit# 40 I — I US
Building Location: /3/ 4LEAsR/u r ST Owners Name: EP/e l anpF2
P i3.gsr gii/E/L
Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential X
New:❑ Alteration: Renovation:❑ Replacement:❑ Plans Submitted: Yes❑ No❑
FIXTURES •
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Check One Only Certificate#
Installing Company Name: EY:14//A/SLOW, rig,
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,r l Corporation /425--
Address:2REai€?oM OPriF1 city/Town: olrr��. }/AIPliOC'n# State: MA
❑Partnership
Business Tel: 506'-394 -777A Fax: 508-314/' 2S6 ❑Finn/Company
Name of Licensed Plumber: E. F. W/NS'GO&silt
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 Yes,please Indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy X 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
Check One Only
Owner 0 • Agent 0
Signature of Owner or Owners Agent
I hereby certify that all of the details and information I have submitted(or entered)re: rdin• this application are true an ccurate to the best of my
Knowledge and that all plumbing work and installations performed under the perm' is • •r this pplication will be compliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 0 .h ,-ne al .
By Type of License:
Title Plumber Signature of Licensed Plumber •
City/Town Master License Number: 7939
APPROVED(OFFICE USE ONLY) ❑Journeyman