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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PL MBING wSP
•, Px--Int or Type)
9
Mass. Date e-
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City, Town Permit #
Building Owner 's
AT: Location C/P Name /51 i
4,-f A—za- _ Type of Occupancy:.._��it�
New Renovation ❑ Replacement ❑
Plans
FIXTURES ❑
Submitted: Yes ❑ No
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SUB—BSMT.
BASEMENT
iST FLOOR
2ND FLOOR I r
3RD FLOOR
4TH FLOOR
STH FLOOR
BTHFLOOR
7TH FLOOR
8TH FLOOR
(Print or Type)
Installing n �,��., ,,,�.�_ /�//') w z Check one- Certificate
4VLitr iaS L.u•.IG J/ �. • _ .1/,/�..�.,
_ Corp.
Address_ 0 V e ❑ Partnership^�
r
_ ey 77- P1 ❑ Firm/Company
Business Telephone ,��Y '�� Name of Licensed Plumber
I hereby certify that all of the details and information I have submitted(or entered)in above application are(rue and accurate to the best of my
knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent pro-
visions of the Massachusetts State Plumbing Code and Chapter 142 of the Cener a.
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By " ature ofV Licensed 6x6lb"er
Title Type - Plumbing License
City/Town: License Numb erMaster ❑ Journeyman
APPROVED (OFFICE USE ONLY)
Date ............ .... ....................................19..a
Plumber
.....
Owner ........... ...
Address ...................... ....... .....
...............................................................