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1 .� MASSACHUSETTS UNIFORM APPLJCATION FOR PERMIT TO PERFORM PLUMBING WORK
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._ h 3 CITY kia'Imo Utn ) ,� MA DATE 11 ( I D PERMIT#/)Laf'0Ofl5
JOBSITE ADDRESS GII elft (*It OWNER'S// NAME2 gra-Alt Ut 6,29_
POWNER ADDRESS 50wa— TEL b n 6OSOS5SFAX
TYPE pR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL( I
PRINT
CLEARLY NEW:0 RENOVATION:15 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
FIXTURES 1 FLOOR—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB I'
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/01L/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM •
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER '
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) "f3sa=�
KITCHEN SINK i a i
j LAVATORY Z •
ROOF DRAIN ' ;
'
I SHOWER STALL : I ' - '
SERVICE I MOP SINK •
TI OINAL ILET a. ®�,___
WASHING MACHINE CONNECTION 1 -
WATER HEATER ALL TYPES q
II WATER PIPING
1 OTHER ,
�I INSURANCE COVERAGE: —/
i I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES)y NO 0
Z IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
WLIABILITY INSURANCE POUCY d OTHER TYPE OF INDEMNITY 0 BOND 0
9 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
'r CHECK ONE ONLY: OWNER 0 AGENT 0
'`' SIGNATURE OF OWNER OR AGENT
V 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 I ' nce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME 114 4 I Lope-z_ LICENSE OM$i . IGNATURE
MP JP 0 CORPORATION 0# PARTNERSHIP 0.## LLC els
COMPANY NAME L BZ Ptu,„LV V
it " Anhui tuiJ ADDRESS vet/ dd•��4,1
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CITY 8hl dVLrcJ4r— (/ nSTTATE'4. ZIP GI333 TEL
FAX CELL�L�'� J"17"' Opt EMAIL � , ��
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes Na
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMITS �c��r " /J1--& 6
FLAN REVIEW NOTES Z-Rt4
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