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MASSACHUSETTS` / UNIFORM APPLICATION FOR PE IT TO PERFORM PLUMBING WORK
^` CIN YAP.R/t�t'J u�/y . _ MA DATE yI Of / PERMrr#l P/9 OO/7q/5
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JOBSrfE ADDRESS f //6(1b WS WAY OWNER'S NAME J0& 5/ `(14
POWNER ADDRESS /S SKe':ws t.(/4 fJ TEL 5C9-29 Z 7V FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 /EDUCATIONAL ❑ RESIDENTIAL[r,��
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:Er PLANS SUBMITTED: YES❑ NO 0
FIXTURES 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/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER a e+�- re E 3
DRINKING FOUNTAIN 1 Logi LJ
FOOD DISPOSER
`7t..CP
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) • L134NCd MCNT
_ KITCHEN SINK i ay _
LAVATORY -- - '.
ROOF DRAIN 61)
SHOWER STALL ---
! SERVICE/MOP SINK
TOILET I
URINAL �/
l
WASHING MACHINE CONNECTION Vc
/, !/WATER PEANGR ALL TYPES LWATER PIPING
OTHER
iINSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TIRE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITYINSURANCE POUCY 0 OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAVER:I am aware thatthe 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.
Q CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
I<I I hereby certify that all of the details and information I have submitted or entered regarding this application a e a as -to the best of my knowledge
and that all plumbing work and Installations performed under the permit issued for this application will be I mplla i �lI Pertinent provision of the
Massachusetts State PlumbingluCode and Chapter 142 of the General Laws.
PLUMBERS AME 170 . Ci41//,wts LICENSE# 1370/. /,rC SIGNATURE
MP IJP❑ CORPORATION❑# PARTNERSHIP Q# LLC 0#
COMPANYYN,AM`E/ b/ACL eitlifh7ADDRESS SLS AlA f v lCITY {W IVA5 r, STATE /44 ZIP 02-4C/9/ TEL
FAX CELL EMAIL %d :c/J/3 �a 195/. /
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