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NAME AND ADDRESS OF BUILDING NAME CERTIFICATE NO.
CORPORATION_
't.3.0 gy PARTNERSHIP
FIRM OR COMPANY I
NEW OR RENOVATION
NAME OF MASTER OR JOURNEYMAN PLUMBER
NAME OF OWNER—
ADDRESS OF OWNER &-230 �u ADDRESS—
PLANS SUBMITTED? YES TELEPHONE NUMBERS: '
NO ✓ BUSINESS
ESTIMATED COST OF JOB lt� RESIDENCE 73�O�nf�
I hereby certify that all of the details and information 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 provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
f� Signature of Licensed Plumber
Designation and License Number of Plumber
FORM 1240 HOS9S b WARREN. INC., REVISED SEPT. 1973