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7
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type)
Off-4 7� Mass. Date_ ' 19
City, Town Permit # _
a •' Building / Owner ' s
AT: Location ,`" gd ,�u rt.' t 3s` (; NamVies, p �
Type of Occupancy: 1 P s
New ❑ Renovation ❑ Replacement
Plans
FIXTURES Submitted: Yes ❑ No
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SUB-BSMT.
BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR
5TH FLOOR
6TH FLOOR
7TH FLOOR
—L±E
8TH FLOOR
(Print or Type)
Installing Company Name ftj j,4 d a j , Check One: Certificatp
❑ Corp.
Address ( /y MARker' Sr, ❑ Partnership
° » , a t[]' F irm/Company r'
Business Telephone,6-,'?'q-3Cj / ,' Name of Licensed Plumber
I �
I hereby certify that all of die details and information I have submitted(or entered)in above application arc 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 Licensed Plumber
y e of Plumbing License
Cit y/Town: � ..
'' APPROVED (OFFICE USE ONLY)
License Number LJ Master 11 Journeyman
Noo 2978
Date .................... !.��........... ....................
Plumber ....................... .......................................................
Owner ..................................................................................
Address .........................................................................
..............................................................................................