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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type)
X351 -.2 3)
Mass. Date _P;,� � �/_ 19 6
City, Town Permit #
a Building Owner 's
AT: Location 1 I� >
�� � I I �� )�� Name_ � � t 1\ 1 �• � ` ,�. _�.I__
Type of Occupancy:_
New Renovation ❑ Replacement ❑
FIXTURES Plans
Submitted: Yes ❑ No ❑
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SUB-BSMT.
BASEMENT
1ST FLOOR
2ND FLOOR r�
3RD FLOOR
4TH FLOOR
5TH FLOOR
6TH FLOOR
7TH FLOOR
6TH FLOOR
(Print or Type)
Installing Company Name �l�'y` �� %c> i�' ►> Check One: Certificate
• q SS [Zr Corp.
Address /� /1y/+ (/1' I�' l.� ❑
Partnership
❑ Firm/Company
Business Telephone y' 7(, e ,4 ,1)76_ Name of Licensed Plumber
I hereby certify that all of the details and info lion 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 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 Licen ed Plumber
Cit Town: Type of Plumbing License
y/ //'. .
APPROVED TOFFICE USE ONLY? License Number Master 0,-Journeyman
3 w/t $53.00
1 kis
3 1 av
1 b/t
1 s/s 3
1 d/w
1 d"s
1 h/w/h
25 Sept 86
Date ......................................................................19..............
Roy E. t'li.fford
Plumber ................................................................................
Owner Ben & Ray Cons t. Co.
....................................................................................
Lot # b rr Lane
Address
House �� �ayberry Lane
........................................ ...............................
New Home
...............................................».....................................................
1