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•. • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMITTO PERFORM PLUMBING WORK
_Nj= ' CITY�QrM0L MA DATE q-3, 1� . PERMIT# is,,,_,7-10/69
JOBSITE ADDRESS 33 C re, l rint/l e OWNER'S NAME PGl/12 r
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT 131
CLEARLY NEWT RENOVATION:0 REPLACEMENT:Pit PLANS SUBMITTED: YES 0 NO 0
FIXTURES 1 , 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/OIUSAND 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 •
ROOF DRAIN
SHOWER STALL •
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER /� 1
S_c' P.i (1 -pt- t ef n /
-_ ,
ir!r-___-,ti it INSURANCE COVERAGE:
,d have�curr@nt liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YEE NO 0
.�If YOt`f1iHE`CKED; ES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
a` ! CO LIARI INSURANCE POUCY 4' OTHER TYPE OF INDEMNITY 0 BOND 0
I ( ) I
WI 'S INSU NCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
13
U rassasEhusejts eneral Laws,and that my signature on this permit application waives this requirement.
a: f i5
,• co a CHECK ONE ONLY: OWNER 0 AGENT 0
IGNATURE OF OWNER OR AGENT
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 corns i si corns 'th all Pertinent provision of the
Massachusetts State PlumbingCode and Chapter 142 of the General Laws.
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PLUMBER'S NAME 1/1/1a -L v4LICENSE# /J l� SIGNATURE
MP� JP 0 y� CORPORATION❑# PARTNERSHIP❑# Val
❑#
COMPANY NAMEI M441r Rr(7S• �j1 ',24r// ADDRESS (2/ A/. /12- .al rec-2Si—
CITY X10 Iry re STATE ./1. ZIP 40-116 TEL .0
FAX CELL EMAIL
•
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL(INSPECTION NOTES
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Yes No /-tc O/2 2 eP tf 9///6
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES