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t. �+ MASSACHUSETTS UNIFORM APPUCAT1ON FOR A PERMIT TO PERFORM PLUMBING WORK
=L7=" CITY yi5'l?. QIP MA DATE?—?O —�/F PERMIT#I 6710(:°5-t?
JOBSITE ADDRESS( t/ • `' In 'c .6:4_________ OWNER'S NAME / n U 4�
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTAla/
PRINT
CLEARLY NEW:0 RENOVATION: REPLACEMENT:0' .PLANS SUBMITTED: YES 0 NO 0
FIXTURES 7 FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 '12 13 14
BATHTUB
CROSS CONNECTION DEVICE I
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/01USAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM •
DEDICATED WATER RECYCLE SYSTEM .
DISHWASHER •
DRINKING FOUNTAIN
FOOD DISPOSER '
FLOOR/AREA DRAIN . —_ ,
INTERCEPTOR(INTERIOR) I t.. , v l.. it i
KITCHEN SINK ' E 4 w~ . ' 1 r
LAVATORY ��.,TT� t
ROOF DRAIN I Ai- 3 W 1
I SHOWER STALL F- 1 , _..J •
• SERVICE 1 MOP SINK I L[
TOILET / - L —
URINAL
WASHING MACHINE CONNECTION
WATER HEATER.ALL TYPES
WAILKPIPING _
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO 0
IF YDU CHECKED YES, PLEASE INDICATE THE E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY INSURANCE POUCY OTHER TYPE OF 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 '
1 Massachusetts General Laws,and that my signature on this permit application waives this requirement
_ CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
1-1.1 I hereby certify that all of the details and information I have submitted or entered regarding this application are 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 m an II Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. pper�//
PLUMBE ' NAME LICENSE#37b7 . SIGNATURE
MP gJP❑ CORPORATION 0# PARTNERSHIP 0.# LLC 0#
COMPANY NAME aCer/6 ,C11 fit, ADDRESiJ - /c77
CITY W -a 1 c 7/Yr STAT ZIP A7CVC TEL CW-1,0/J
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FAX CELL EMAIL
Lie
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ ,Aj L n O,
FEE: $ PERMIT tT
PLAN REVIEW NOTES A 0
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