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MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK ,
�— — o d`t PG21 MA DATE 02_ —a.C (Y PERMIT#Ai= t/P'' Oy7V/
CIN V�2m � � � C
JOBSITE ADDRESS S3. Si3rtit& C. I I,C OWNER'S NAME /9-(a2 -PoPIe1-.A,c.lQ
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL❑
PRINT
CLEARLY NEI RENOVATION:0 REPLACEMENT:0• PLANS SUBMITTED: YES 0 NO 0
FIXTURES 7 FLOOR—, BSM 1 2 3 4 5 6 7 B 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 7
INTERCEPTOR(INTERIOR)
KITCHEN SINK I
LAVATORY •
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK
I TOILET 1 1
URINAL -
WASHING MACHINE CONNECTION /
WATER HEATER ALL TYPES 1
WATER PIPING
OTHER
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YEAa NO 0
IF YOU CHECKED YES, PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILJTY INSURANCE POUCY OTHERTYPEOF INDEMNITY 0 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
CHECK ONE ONLY: OWNER 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT
4.1 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 compliant= '. -=II P6(tinent rovisiou.nf the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME mnr Sc IO)t,-r� ! ���
LICENSE# 2�-�(,f SIGNATURE
MP 0 ' JF CORPORATION❑# PARTNERSHIP Q# LLC❑#
COMPANY NAME MOT Swotern PiumI -di ADDRESS SCS YoJ ii-oust. �1/c�'Q� ] p
CITY AJ OU.4J L\ STATE f r7 ZIP c C Q I TELS?' L] lat a I
FAX CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No •
pv �/ �,/ //e d THIS APPLICATION SERVES AS THE PERMIT 0 ❑ j'1���^�.0,
4A70.
�C/O (C' / V /`(//`�1� FEE: $ PERMIT 8 J / '` 5IA9r1C
/ PLAN REVIEW NOTES
Past PL C ,L 0G-,/� /laoii
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