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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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L CITY Yi7r41#Urtj MA DATE '1,4>,JIP, PERMIT#JJL✓I/7—I9-4004 VS
JOBSITE ADDRESS I\ (scuff— 9,a A4 itti. OWNER'S NAME 5fPJE LIST
POWNER ADDRESS TEL T)9 t1L1-15914 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL Er
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:6 PLANS SUBMITTED: YES 0 NO-Er
FIXTURES 1. FLOOR-4 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/OIL/SAND SYSTEM _
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM •
DEDICATED WATER RECYCLE SYSTEM .
DISHWASHER 1 • 1
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK I
LAVATORY
ROOF DRAIN If_ 0 r . 1
SHOWERRSTALL Y
• SERVICE I MOP SINK t i
I TOILETI ,-u�I 1 1N
URINAL 1 L
• I WASHING MACHINE CONNECTION U 1
WATER HEATS ALL TYPES 1 1/ 10'
WATER PIPING
I OTHER
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INSURANCE COVERAGE: / 1
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES N0 0 I
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter'142 of the
t Massachusetts General Laws,and that my signature on this permit application waives this requirement
2 CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
thereby 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 Chapter 142 of the General Laws.
PLUMBER' NAME NACA E'_ it_ `-i onto lR+- hill S LICENSE \C . SIGNATURE-
MPle JP❑ CORPORATION❑# PARTNERSHIP Q# LLC❑#
COMPANY NAME E ftu m:1C PtunnF, a HfnTtriCs ADDRESS 13c Chet/kill SMALL- ICD
CITY S. YekbaA•JTtA STATE 04A- ZIP 024404 TEL-I'1`I-r9Y- i8'jy
FAX CELL EMAIL LPPt-Lc\CCPwr.^6WC,e 'GkNCO eats\
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY ANAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS_THE PERMIT 0 0 f� y� -
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FEE: $ PERMIT It gym44tt /2 k .Qv( c
• PLAN REVIEW NOTES /l ,P/74- �j�y,F
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