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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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�G\ MA DATE 1? /7 PERMR#044/VR00/2/f
JOBSITEADDRESS 7j.- n(r pyJNER'SNAME E]j/€ �£t4jii 'i'�l� C�(1
P OW1MERADDRESS - 'D• 1)-D( g%/9''S. a.NYIh c TEELRSol 6-6,4-16VLy /
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TYPE OR OCCUPANCY TYPE COM RCIAL 0 EDUCATIONAL 0 RESIDENTIAL 1K
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PRINT
CLEARLY NEW:0 RENOVATI REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
FIXTURES 1 FLOOR-. 8511 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB II
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM _
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER 1`
DRINKING FOUNTAIN "
FOOD DISPOSER - r , s e V E if
FLOOR f AREA DRAIN
INTERCEPTOR(INTERIOR) A
KITCHEN SINK t' /i 2 .; 2071
LAVATORY I. t
ROOF DRAIN B I LI- _
SHOWER STALL ( , a, — ,_ 'i.—
SERVICE/MOP SINK
TOILET t f
URINAL
- WASHING MACHINE CONNECTION- •
WATER HEATER ALL TYPES
WATER PIPING E I) F i
OTHER
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INSURANCE COVERAGE: BUILDING DttPAh r T
I have a current liability insurance policy or its substantial equivalent which meets the requirements of M.•Lek 142. YES LJ_No
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
r INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND 0
OWNE:' SURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massac r,:tts General • and that my signature on this permit application waives this requirement
41 .„ r /..arAli31 CHECK ONE ONLY: OWNER rtICGENT 0
S1%90174- AM ER OR AGENT
I here. certify that all of,-details and Information I have submitted or entered regarding this application are and acarate to the best of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application vAn be In [lance with as nerd provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NA,,M,,E//A nsrr tr h LICENSE# 524 sr- SIGNATURE
MP❑ JP L7 CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME Avis, 6Ia,
AA,,��AA ADDRESS 24 I'iel i hc(3I ane go
CV St* - Cgavmaui1ySTATE'JUA ZIP t17 ces ft TEL rCC/�3R'ZCLa4-ne
FAX CELL EMAIL
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