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MA S/�AfCH�USElTTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ,7
CITY tl�l r Y CILA MA DATE l` Z P MIT# _// 9-60 L\ (GCT'J
JOBSITE DRESS Z SO-44 '84- t OWNER'S NAME ((4-111 Los `C6t)
POWNER ADDRESS TEL FAX
TYPE OR OCCUPAN Y TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL ty
PRINT
CLEARLY NEW: RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES 0 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 •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
1 LAVATORY
ROOF DRAIN
SHOWER STALL OA'1 L�
• SERVICE 1 MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
I WATER PIPING
OTHER
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INSURANCE COVERAGE: CO
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 E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUT?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
Massachusetts General Laws,and that my signature on this permit ap?lication waives this requirement
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
L:l I hereby certify that all of the details and information I have submitted or entered regarding this application are and ac to the best of my knowledge
and that all plumbing work and installations performed under the permit Issued for this application will In fiance 'th I Pertine provision of the
Massachusetts State Plumbing Code andmeChapter 142 of the General Laws. v
PLUMBERS NAME�t lcJcG r ekLICENSE#7.-05i C. SIGNATURE
MP❑ JP Ir CORPORATION 0# PARTNERSHIP Q# LLC❑#
COMPANY NAME TO Q\U�✓`� (•0 ADDRESS �b na-- �
CITY �v�4 STATEkM4 ZIP ab��� TEL J"g^Z&—(03(p-7
FAX CELL EMAIL
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