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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
'eater' CITY ��,.'Rrle..rN MA DATE L/— /9— 2o/3 PERMIT# "P I17 7/.�
JOBSITE ADDRESS yN RT.2.7 kec g'i y44rrsrr/' OWNER'S NAME Jo$A /amnio
POWNER ADDRESS TEL I SD75-44.GSo3 FAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL® EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:0 RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO 0
FIXTURES 1 FLOOR-. BSMT 1 2 3 4 5 5 7 B 9 10 11 12 13 14
BATHTUB _
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYS
DEDICATED GAS/OIL/SAND SYS _
DEDICATED GREASE SYS
DEDICATO GRAY WATER SYS
DEDICATED WATER RECYCLE SYS _
DRINKING FOUNTAIN
?A° DISHWASHER
FOOD DISPOSER _
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY. _
- ROOF DRAIN= -
SHOWER STALL -
SERVICE I MOP SINK
TOILET _
cztURINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
a1 1OTHER Sic kit .1.
1-1^.-1-�.-� +sN t,� 1
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which,meets the requirements of MGL Ch.142. Yes No 0
IF YOU CHECKED YES,PLEASE INDICATE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND 0
`y) OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement
` - CHECK ONE BOX ONLY: OWNER 0 AGENT 0
YJ Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the
best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chap r 14 f the Ge I Laws.
PLUMBER NAME S`n Art-5-0 Ft . SIGNATURE
UC# 2-3 G/L MP❑ JP tr CORPORATION El# PARTNERSHIP ❑# LW [9"#
COMPANY NAME fT/A, 50/.- Ft 1-1 ADDRESS: /336— C4.'41'1/ /R` e
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CITY —QST /ice.,/.H STATE/41a' ZIP 02ir3 L EMAIL. g5//c fe7/4-1.1 a, /-f 0 I I. co"
TEL 5o7 LGAL ,, I 1 C S07$'6G G-2-3! FAX ,C15?0541C
BJ t SoF 5-‘3 C2-3
ROUGH PLUMBING INSPECTION NOTES THIS 1'AGF,FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
I„1
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES