PP-082 f'yl
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type)
perfmovFh ,/
N — ,e ,�yh. Date q _ 7--c17
1 iil ff Buildin Location 15 SvYIGlon&, t i2d.
fi_ V 4 permit
-tvi�:� is Owner's Name Yf IGI#hcf ww V tin e
iY
New Renovation Replacement Plans Submitted
FIXTURES
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A1 SUB—BSMT. ,
BASEMENT �7 I
1ST FLOOR /
/ 0\i 2ND FLOOR 'a l a p _I i
Il 3RD FLOOR
. 4TH FLOOR
5TH FLOOR
6TH FLOOR
7TH FLOOR
8TH FLOOR
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(Print or Type) , Check One: Certificate
Installing Company Name /4nd 0 T�"(y 1 e riOne, �
, ❑ Corp.
Address 3/ DOG(IC 5 T J
-f G i 1-ho)tg h , fn�/G ❑/Partnership
i / 55 9 Firm/Company
Business Telephone q C7a-310 1 Name of Li nsed Plumber
h�reit/ .-1S-, Pen6n
Insurance Coverage: Indicate the t e of insurance coverage by checking the appropriate box:
Liability insurance policy [j( Other type of indemnity ❑ Bond ❑ '
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this
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application does not have any one of the above three insurance coverages.
Signature of owner/agent of property Owner ❑ Agent ❑
I hereby certify that all of the details and information I have submitted(or entered)in a e application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under Permit issued r thi application will be i ompliance with all pertinent
provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
y Signature of Licensed Plumber
B ' <C.
_ Title La€4,,A4 26.5a
- �y/Town - 'rd �ee4tr�c� Type of Plumber License
APPROVED (OFFICE USE ONLY) 07SiG(� 0 Master 'Journeyman
License Number
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