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MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM PLUMBING WORK
L CIT`t-O&ACrYYJ(7 MA DATE {Fig 6 PERMIT#40. 'Se _029_g
JOBSITE ADDRESS (a •3 L.1C 1 Nue. OWNER'S NAME, tcn mare YW.r
POWNER ADDRESSap�;J(Ze-r-k A- TEL. -iLb?� �0' FAX
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TYPE OR OCCUPANCY TYPE OMMERCIAL 0 1 ~ EDUCATIONAL 0 RESIDENNTIALXs-
PRINT
CLEARLY NEW:0 RENOVATIONS REPLACEMENT:0 PLANS SUBMITTED: YES 0 NOB.
FUTURES 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/OILISAND SYSTEM
DEDICATED GREASE SYSTEM _
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER •
DRINKING FOUNTAIN
FOOD DISPOSER
BOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK f
LAVATORY f
ROOF DRAIN agate!. I
SHOWER STALL L T •
SERVICE/MOP SINK •
TOILET
URINAL { ASG 201G
WASHING MACHINE CONNECTION _
WATER HEATER ALL TYPES
uc .+fin rvv4j
WATER PIPING °- - /1
OTHER p3eji-n r
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESX NO ❑ •
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY INSURANCE POLICY Zs- OTHER TYPEOF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WANER: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 ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
VI 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 an plumbing work and Installations performed under the permit Issued for this application will be N campliance with al rtnt n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME f i G•tnO)aS g))k LICENSE#?L 3 a3 3 SIGNATURE
MPD - JPS-,j _.` CORPORATION 0# PARTNERSHIPQ# LLC 0# Z -/�//"
COMPANY NAME M�4�Gtzi% r Jr- ADDRESS e' S ri!)V•Ylm .W ( Coc
CITY NYArakz2re, C l'r)) _ STATE r ZIP C22&I-)9J TEL j4-yf•
S
FAX CELL EMAIL \..a =/ _ i si t :5 1
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0 ,vn
FEE: $ PERMIT It / / / � // I-0 t
PLAN REVIEW NOTES _
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Commonwealth of Ma usetts
Division of Registrati
Board of plumbi
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PL33839-J 05/01/2020 006807
License No Expiration Date Serial No.
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