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1 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
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CITY YA,Cnourr14 MA DATE —j }rI t 81 PERMIT# 'I �" I1p�0%p•
JOBSITE ADDRESS 24 REM au-r OWNER'S NAME 1-�Ot1 ',ceitII12Fi
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POWNER ADDRESS TEL-J?9 -310'3.`Ia 4S-FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL®
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:RPLANS SUBMITTED: YES 0 NO❑
FIXTURES 1 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB I• _ 1
CROSS CONNECTION DEVICE _ •
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM _ •
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM •
DEDICATED WATER RECYCLE SYSTEM -
DISI-WASHER / •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN -- 1 _
INTERCEPTOR(INTERIOR) _ C L: 1. e 1:: ••1
KITCHEN SINK I ' 1
LAVATORY �_... �. , I
ROOF DRAIN F C 7 u l 1
SHOWER STALL IT •
• SERVICE I MOP SINK tui ...v. i VADI J
TOW jr _ _ _
URINAL
iWASHING MACHINE CONNECTION I —
WATER HEATER ALL TYPES
WATER PIPING L
OTHER
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INSURANCE COVERAGE: l
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES P NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY tie 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
1 Massachusetts General Laws,and that my signature on this permit application waives this requirement
•' CHECK ONE ONLY: OWNER ❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
ka 1 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 Imowledge
and that all plumbing work and Installations performed under the permit issued for this application will be in mpliwith all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER'S NAME VEVIN t, SPRY LICENSE#IS9bv . SIGNATURE
• MP • JP❑ 11 CORPORATION❑# PARTNERSHIP Q# LLC®# 3S-4 8'
COMPANY NAME Sers J PLI o-. ds n% qt%n,s L1.C. ADDRESS 9 a T. A%u S-h-ic W call tr< 4 D
CITY e-UC.k.lnft_j STATE H 4 ZIP 0.1-31 0 TEL, yl- `t R3- oaj./
FAX CELL//1-70.-OIacj EMAIL
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY ,FINAL INSPECTION NOTES
Yes No
$61- /�� O� THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ /11/6—
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, FEE: $ PERMIT A / V/[/ /If 7
(1- 7/0/1 FLAN REVIEW NOTES
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