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- , MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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_.�- , Mass. ' Date E 19 C S
_ ` _ City, Town HEALTH
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('i , V 12 m C U T N ' Type of Occupancy: CZ 111)•V' e IZ.C° I A I
New ❑ Renovation E Replacement El
_______ FIXTURES Plans Submitted Yes ❑ No El
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BASEMENT , \(
1ST FLOOR "f / a
2ND FLOOR "`///
3RD FLOOR
4TH FLOOR
5TH FLOOR
8TH FLOOR
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(Print or Type) CheckiCorp.
: Certificate
Installing Company Name PE I�R-y 13 C C_D Lt/t -t,tC
Address K-- e •
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❑ Partnership
S-", C‘'‘- a_T-1 ot_,0 --- ❑ Firm!Company
Business Telephone (//,3,2 ge 4-7 Name of Licensed Plumber or Gasfitter
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 Permit issued for this application will be in compliance with all pertinent
provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
I have informed the owner or his agent that I do not have liability insurance including completed operations coverage.
Signature of Owner Agent
I have a current liability insurance policy to include completed operations coverage. 0
By clef/lure of Licensed Plumber
Title /
City/Town Type of Plumbing License
ix 9 L'I Master ❑ Journeyman
APPROVED (OFFICE USE ONLY) License Number
FORM 1240 l I{&W) Hoses a WARREN TM
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