PP-3808 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
ems\ (Print or Ty-e: >�7��� -7
(t , Mass. Dale�U• "6 1g Permit il
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_j'r.IICing LOOa?ion �(� l � f Pi �JZ!' l
`i 'Owner's Name
%�1 Tyre of Occupancy
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New Renovation = Replacement _ Plans Submitted: Yes C No
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V _ a N o C- - I _I I = IC 71
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SUS-9S.}I . I I I I I 'I - I I I I m® I I I IIIIIII
eASEMt NT I I I I I I I -1 I I all I
1ST FLOOR QAMMIummaI I
r SRO FLOOR I I I I I I I I I I I I Eliarneirminamiesum
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Z 4TH FLOOR I I I I I I I I I I I I I I I ■�
/2jr�c/ 5TH FLOOR I I I I I I I I I I I I I I i I I Ell
J & 6TH FLOOR I I I I I I I I I I I 1 I I I I I I
/� 0 IL 7TH FLOOR I I I I I I I I I I I I ��
eTH FLOOR �` ■
Installing Company Name�r 2)oL/y CS )0/3 /2/� Ch ck one: Certificate
Address /, i
(�`2/ '" � ' `" L V1/2�,���7� ) �- Corporation
/X/ / PM 0'� / `- o� 'I v Sd 6 E Partnership
Business Telephone 2 2-77—/JS 9/ �, " = Firm/Co.
Name of Licensed Plumber rf�b( Y a- /�ykV/ 4O1,tC �7/
I INSURANCE COVERAGE: % �•/ __ v/�.
I have a;curre tel' ility insurance policy or its substantial equivalent wnicn ,meets the requirements of MGL Ch. 142.
Yes r- No '_
If you have checked yes, pleas cafe the type coverage by checkin_ the appropriate box.
A liability insurance policy _. Other type of indemnity = Bond =
OWNER'S INSURANCE WAIVER: I am aware that the licensee c-es -zt -2ve the insurance covera^e required by
Chapter 142 of the Mass. General Laws. and that my signature or tr.:; -_r_.m:: application waives this requirement.
Check one:
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Signature of Owner or Owner's Acer: -^Per - Agent
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I hereby certify that all of the details and information !ha' - sub itted for entered.- _
tor knowledge and that all plumbing work and installation ,.error -d under the pe:—: are trueit andin accurate compliance the best of my
pertinent provisions of the Massacnusetts State Plump ng Co•e an• hapt r - ' J'Is acc.lcatio ill be in with all
�j` Laws.
Ey ✓�//a.' Loa
Tice i;nature , Licensed lumbee
Ctv/Town Type of License: Master e _:_.nneyman
APPROVED(OFFICE USE ONLY) License Number 7005 3
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