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MASSACHUSETTS UNIFORM APPLICA1iun run rrnmi i : v uv mmma:nu
(Print or Type) aq
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Mass. Date _
City, Town e Permit N
i Buildinq Owner's
AT: Location //a 4(45 'fyo Name Ir9,9 ,_,� 7 �y
Type of Occupancy:
New Renovation ❑ Replacement ❑
Plans
FIXTURES Submitted: Yes ❑ No ❑
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BASEMENT
1ST FLOOR
!ND FLOOR /
3RD FLOOR
4114 FLOOR
ITH FLOOR
ITH FLOOR
ITH FLOOR
ITH FLOOR
(Print or Type)
Installing Company Name Boulanger's Plumbing A Check Ones Certificate
ea ng, Inc. ® Corp. 387-C
Address 373 ftin Street, P.0 Box 89 ❑ Partnership
Sssthupton, MA 01027 ❑ Firm/Company
Business Telephone A 536-8845 Name of Licensed Plumber
Davits C. Teece
1 hereby artify that.all of the details anti information 1 have submitted(or entered)in alwrve appliceiinn ere itwe and oeewtaM to the bed of nrr
knowladp ad that all plwmbind work and insteltatiuns twrformed under Permit hued for this application win he in eor"PUenoa wNh aN pertinent pro-
visions or the mastechussits State lilvinbin(t Code and Chapter 143 of the Geneial Laws.
By
Title _ Signature of Licensed Plumber y
City/Town: Type of Plumbing License
2958
Date ......................... .`.............................-.—M..........
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Plumber .......- :' .... .... ; .... ............
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Owner .............................................................................. ..
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Address r.. _ ..................................
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