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� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
C�n' j�/ 'r/ v �I G�I�" ,l MA DATE � '-' � �-�� PERMIT#�OP/�v'�?/��J
JOBSITEADDRESS ..2 � �-{1 ��► S� �-U C✓ GI�' t� t�r( OWNER'SNAME j Y� � /� �'Pl��a� �I
POWNERADDRESS �� � � hf � �� �J���/ ��TEL FAX .
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TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL��
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CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES Z 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/OILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAW
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN �
SHOWER STALL
SERVICE/MOP SINK
TOILET
U RI NAL
WASHWG MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER ��
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INSURANCE COVERAGE:
I have a current liabilitv insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO ❑ �, I
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IF YOU CHECKED YES,PLEASE INDICATE THE TYP COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW �
LIABtLITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND ❑ �
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
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Massachusetts General Laws,and that my signature on this permit application waives this requirement. �
CHECK ONE ONLY: OWNER ❑ AGENT ❑ �
SIGNATURE OF OWNER OR AGENT � '
I hereby certify that all of the details and information I have submitted or entered regarding this application ar ru d a rate t best of nowledge
and that all plumbing work and installations performed under the permit issued for this application will be i m ' nce with I e ' nt pro on he
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ^Q �
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PLUMBER'S E LICENSE#�Q I�1 SIGNATUR �
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MP ' JP❑ r CORPORATION❑# � PARTNERSHIP❑# LLC r�# � ���.�
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COMPANY NAME �P LU �' ADDRESS�s � �v �dd�??�/'�(a, � U �
CITY��_/�� , ,�f1 � STATE��� ZIP �����_ TEL``..���`/�`��� '
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