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� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PER ORM PLUMBING WORK
CITY_ /n! � �/'FF2vy MA DATE lb ?a .
� ERMIT# �/JP/�'� �
JOBSITE ADDRESS L b� �-C /S v.v " L.v ONMER'S NAME V P T /`/} N !�
POWNER ADDRESS TEL Fp,X
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESID NTWL�
PRINT
CLEARLY NEW:❑ RENOVATION:� REpI.qCEMENT:❑ PLA S SUBMITfED: YES❑ NO❑
FIXTURES 7 FLOOR� BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GR4Y WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR INTERIOR
KITCHEN SINK
LAVATORY
ROOF DR41N
SHOWER STALL
SERVICE I MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER j �y c (
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I have a curcent iabili insurance policy or its substantial equiva eM wh c�h mee�ts the requirements of MGL h.142. YES NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
G?� `:
LIABILITY INSURANCE POLICY� OTHER TYPE OF INDEMNITY ❑ BOND ❑ `
OWNER'S INSURANCE WAIVER:I am aware that the licensee dces not have the insurance coverage required y C aptero142 of the G�,5
Massachusetts General Laws,and that my signawre on this permi[application waives this requirement. H�P,(TI-; C�PT.
SIGNATURE OF OWNER ORAGENT CHECK ONE ON Y: OWNER ❑ AGENT ❑
I hereby certify}hat ail of the details and infortnatlon I have submilted or entered regarding this application are true and a curate to the besl of
and that all piumbing work and installatlons perfortned under the pertnit issued for this applicatlon will be liance th all Pe ' ro ' i Y f e�9e
Massachusetts State Plumbing Code and Chapter 142 of the General LaWs.
PLUMBER'S NAME � •C/-/A C�E LICENSE# I D 3�� SIGNATURE
MP�-P �P❑ CORPORATION❑# PARTNERSHIP❑# LlC�#
COMPANY NAME � • Cf{i4 C K�- ADDRESS �3? � !�'�A�/ S T
CITY C �l�N.v F � STATE �' "
,� ziP f?� 6 y� €�a �'� �c .� �-�3�/
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