35-233 (6) MASSACHUSETyP UNIFVHM AFFLI%;AI IVN FVN PEHM11 IV UV I LUM NV
(Pr 5
int r Type) Zye 1
Hass. Date 19
City, Town Permit 0
Building �f�!` Owner 's
VAT: Location 6 MM � ' �~ Name
Type of Occupancy. '- `." "`�/
New Renovation ❑ Replacement ❑
Plans
FIXTURES Submitted: Yes No ❑
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SUB-8SMT.
BASEMENT
iST FLOOR
2ND FLOOR y 3
3RD FLOOR
4TH FLOOR
5TH FLOOR
6TH FLOOR
7TH FLOOR
8TH FLOOR
(Print or Type)
Installing Company Name! �0 w 'Z Z= Check on Certificate
i� Corp.
Address 3 f{ d-a� -� �� ❑ Partnerships,
T�'`` r 'j �` - --- ❑ Firm/Company
Business Telephone Name of Licensed- Plumber
r 1 hereby certify that all of die details and information i have submitted(or entered)in aMive application are true and accurate to the best of my
knowledge and that all plumbing work and installations lictlormed under Permit issued for this application will be in compliance with ad pertinent pro-
visions of the Massachusetts State Plumbing Code and Chapter 142 of the General Ljw4�
BY Signature of Licensed lumber
Title Type of Plumbing License
/17 — F4 7 S ..�
City/Town: License Number E, Master ❑ Journeyman
APPROVED (OFFICE USE ONLY) '�
7
Date .. .. �r............ ........................19... ,
Plumberi..:.... ..... .............................
n -
0wner t .....
Address ...............................f............1::�...L:P.... .......
....
............................. ............... ............. ................