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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
R (Print or Type)
Mass. Date o-,l "=- 0 19 5
° City, T" wn permit #
a Building Owner 's
Location , � c < f `1 `'
AT: /.
Type of Occupancy:_1_L
New Renovation ❑ Replacement ❑
FIXTURES Plans
Submitted: Yes ❑ No [I
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SUB—,BSMT.
BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR
5TH FLOOR
6TH FLOOR
7TH FLOOR
8TH FLOOR
(Print or Type)
Installing Company Name Check One: Certi£icatP
❑ Corp.
Address / I 3
❑ Partnership
❑ Firm/Company
Busin ss Telephone�2 7 �6 Name of Licensed Plumber
I hereby certify that all of the details and information 1 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 issued for this application will be in compliance with all pertinent pro-
visions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By
Title Signature of License Plumber
City/Town: Ty e of Plumbing License
rs �
APPROVED (OFFICE USE ONLY) License Number ❑ Master Journeyman
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