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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type) +�0i
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Nat-i� KP4-oh Mass. Date Tg n� 4 19 S�
City, Town Permit #
a Building Owner ' s
AT: Location '3 t R c trt b rook a r_ Name -± rect �✓t!CkLO
Ve Type of Occupancy:
New ❑ Renovation Replacement ❑
Plans
FIXTURES Submitted: Yes ErNo ❑
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SUB—BSMT.
BASEMENT
1ST FLOOR J I
2ND FLOOR
3RD FLOOR
4TH FLOOR
5TH FLOOR
6TH FLOOR
7TH FLOOR
BTHFLOOR
(Print or Type) Richaxd s
Installing Company Name Plg.& Mg. Inc. Check One: Certificate
® Corp.
Address 79 Union Street ,Rear ❑ Partnership
Easthampton'Ma 01027 [] Firm/Company
Business Telephone 413-527-0291 Name of Licensed Plumber
RICHARD A BOULANGER ---
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' ed for this application will be in compliance with all pertinent pro-
visions of the Massachusetts State Plumbing Code and Chapter 142 of the General ws.
B'y -
'itle _ S' gnature of icensed Pl ber
Type of Plumbing License
City/Town:
APPROVED (OFFICE USE ONLY
License Number ❑ Master ❑ Journeyman
I w/c $12.00
1 lav
q
7 June 188
Date ..................................................................... ............
Richard Boulanger
Plumber ..�ict�ad••.y...�lt�atbng.....................
Fred Becko
Owner ..................................................................................._
381 AcrebrooM Driva e
Address ................................................................................
REnovation
.......................................................................................................