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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING q
(Print or Type)
Lj` . /?�,G'j/� Mass. Date / - 7 19 J
x - City, Town -�
Permit #_ —G j
a Building-4 Owner 's 1
AT: Location J ? y / r K Name /—Ay?L ���� (_ L f1 f�-I '�
Type of Occupancy: , 4, Z t-1- 0
New ❑ Renovation Replacement ❑
Plans El
Submitted: Yes ❑ No
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SUB-BSMT.
BASEMENT
1ST FLOOR f I I
2ND FLOOR Z 1
3RD FLOOR
4TH FLOOR
STH FLOOR
6TH FLOOR
7TH FLOOR
8TH FLOOR
(Print or Type) �
Installing Company Name / ,� , �; _ Check One: Certificate
/ ® Corp.
Address�4/ Te��l
Partnership
Firm/Company
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Business Telephone �-� Name of Licensed Plumber
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I hereby certify that all of the details and informalion 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-
p visions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws
By Signat re of Licensed Plumber
Title Type of Plumbing License
City/Town: El Number MasterJEJ Journeyman
APPROVED (OFFICE USE ONLY) P)NTSH P
..............
Date .. .. ...... .................................... ...........
Plumber ...............I.....I.. ............... ................................
Owner . ....................... ..........................
Address ...�/Io....
... .................................................................