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i . -t MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
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CITY YA!'rne-4 xtsc
MA DATE 4-7--Y-i a1X PERMIT#,9zDP-fr-ai/Uj
JOBSITE ADDRESS X11 (fir .. Pr(z-2 OWNER'S NAME C.-14-a'(i3
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:L : REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
FIXTURES 1 FLOOR- BMA 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM •
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER •
DRINKING FOUNTAIN
FOOD DISPOSER _
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR) 04 t!y 1
,
KITCHEN SINK I I' —1'
j LAVATORY •�� L
ROOF DRAIN D 4310t1SHOWER STALL 1
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SERVICE/MOP SINK _sun_ fl:ar�r:(?�+
TOILET l�
URINAL
WASHING MACHINE CONNECTION �'+'
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 4 NO 0
IF YDU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY '"'% OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAVER: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.
st CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
LU 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 compliance ' II Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Scct.n ELrirlkir+G..n LICENSE# /Cg-22 SIGNATURE
MP[11., JP❑ , CORPORATION❑# PARTNERSHIP Q# LLC❑#
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COMPANY NAME 4nfia-har, etGcMbrn C ADDRESS ?c) .3K &fig
CITY CenitnAz tCa STATE P71t ZIP 02632- TEL 774-23E-a2S2.
FAX CELL EMAIL `1cy"rn.1na...-. \ belL?'1.0M e. ct 4n-k
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