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MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBINGWORK
T CITY %lar nnoJ�^ MA DATE 9f r' iI� PERMIT#/340 THOMil
JOBSITEADDRESS III 31-a/l,vc4c L,.\ OWNER'S NAME Dan &A(..nc.0.
POWNER ADDRESS 1 I 1 cJ-- la'JCL l 1,-... TEL 77f'',1/2-0423 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 1
PRINT
CLEARLY NEW IiiI:I RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES® NO❑
FATURES 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/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 a p 1 t
I ROOF DRAIN
' SHOWER STALL _ 4
! SERVICE/MOP SINK I r r
I TOILET MX ' K.
URINAL BOl A5
1 WASHING MACHINE CONNECTION By ilI i
WATER HEATER ALL TYPES i
WATER PIPING tfor x.
l 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 0 NO 0
IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ® OTHER TYPE OF INDEMNITY 0 BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
1 Massachuse General Law ,and that y signature on this permit ap?l'ication waives this requirement.
2 - L CHECK ONE ONLY: OWNER ❑ AGENT In
SIGNATURE % 0 I•
R OR AGENT
LI 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 co priance with I Pertlnen provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ��J/
PLUMBER'S NAME LICENSE#3o,1/o. GNA RE
MP 0 JP 51r CORPORATION 0 it PARTNERSHIP❑.# LLC 0#
COMPANY NAME Bgnws4a1LL :CL, Suu:ce5 ADDRESS 757 'Ra[.a- (0,...g_ W
CITY /ttAdio %5 ;IIS STATE t` ZIP 0-24 Yr TEL 50g-WY-3169
FAX CELL SOB'YIY -.S847 EMAIL & SJ4d/LMecYw„ka e..rats Q
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