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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
4 MA DATE /6'/ PERMIT#AS/9'1?-6041W
=LI=a CITY .�'ysrm 9-/�
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JOBSITEADDRESS 3S Horva. ol SOWNER'S NAME 07,2YA-1,17
POWNER ADDRESS S A /4 TEL Sak'685'S4S4 FAX_
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:IYE PLANS SUBMITTED: YES❑ NO 21
FIXTURES 7 FLOOR-+ BSM 1 2 3 4 5 6 7 6 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
LAVATORY __._9. -- a
ROOF DRAIN
SHOWER STALL test's 9_1111; `moi .
SERVICE/MOP SINK
I TOILET _
URINAL
WASHING MACHINE CONNECTION BIULDrd.3..DF�ARTMHNT _
0
WATER HEATER ALL TYPES 4
WATER PIPING
OTHER
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INSURANCE COVERAGE:
it I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO CEL
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LABILITY INSURANCE POUCY ❑ OTHER TYPE OF INDEMNITY ❑ 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 application waives this requirement
.177) CHECK ONE ONLY: OWNER [V AGENT ❑
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 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 compli ce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# 0.77S " SIGNATURE
MP 0 JP 0 CORPORATION❑# PARTNERSHIP❑.# LLC❑#
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COMPANY NAME �Grk /c'4e ADDRESS 3? oh en
CITY S yarrut STATE/no ZIP 6764 f TEL rt0Fe- 6aes^c3"6S6
FAX CELL EMAIL
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ROUGH PLUMBING INSPECTION NOTES fELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0 �'/O /C� (�
FEE: $ -PERMIT# (5/ ` /-6/ ///�O
PLAN REVIEW NOTES