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Kass. Date 19�
City, Town
Permit #
Buildinq /y Owner's
AT: LocationZ-z 122/y2 -` - Name Jieoe- &,,eeL;,t)
Z20 -4h'gm � Type of Occupancy:
New ❑ Renovation Replacement ❑
FIXTURES Flans ❑
Submitted: Yes ❑ No
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3 o
SUB—BSMT. t
BASEMENT
1ST FLOOR
2ND FLOOR '
3RD FLOOR
4TH FLOOR
5TH FLOOR
6TH FLOOR
7TH FLOOR IH d
.T. FLOOR
(Print or Type)
Installing Company Name/ h_ Check One: Certificate
❑ Corp.
Address Ljj dr,,.���ca - Partnership r
"Company
Business Telephone 1p�5- lJ_' Name of Licensed Plumber
1 hereby certify that all of the details anti information f have submitted lot entered)in atut-application are true and accurate to the beat of my
knowledge and that all plumbing work and instaliatuuns petinruted under Permit issued for this application wW be W cmapliance with all pertinent pio-
visions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By
r
Title Signature of Licensed Plumb r
Ty a of Plumbing License
City/Town: p ' _
APPROVED ZOFFICE USE ONLY)
Licen a Numb re Star ❑ Journeyman
d/, $21.00
i w/c ,
1 k/s
1 lav
I b/t
1 h/wb
11 Sept 86
Date .....................................................................19.............
Pluinber ....Malcolm.B. Cichyy..........................
SteVV Brown
Owner ...................................................................................
74 Conz Street
Address ..............................................................................
Renovation
..................................................................................................