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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
—=at` J CITY Irv. �'triceifr/ MA DATE /6 /� PERMIT �—/ `6G/Il�
LS 67/ 9
JOBSITE ADDRESS iii &/%r7 S'Ow c flL OWNER'S NAME /944r /416111
OWNER ADDRESS TEL.52,7-367 33?6 FAX_
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL[v]'
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:gje PLANS SUBMITTED: YES 0 NO 0
FIXTURES 1 FLOOR-. ESM 1 2 3 ' 4 5 6 7 8 9 10 11 12 13 14
BATHTUB / 7
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM •
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER •
DRINKING FOUNTAIN _
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY / • ? rl C�
ROOF DRAIN _ 1
SHOWER STALL •
1
SERVICE/MOP SINK (L I 0'4 ZinU _
TOILET / f
URINAL UILD NG DEPARTMENT
WASHING MACHINE CONNECTION ---__
WATER HEATER ALL TYPES
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. YES El NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY E OTHER TYPE OF INDEMNITY ❑ 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
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CHECK ONE ONLY: OWNER ❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
LLI 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 b mpliance with all Pertinent provision of the
Massachusetts State Plumbingl � Code and Chapter 142 of the General Laws. hJ�2l�- /) /
PLUMBER'S NAME 7"'rtn £s o X LICENSE# 2 2/76. SIGNATURE
MP
MP❑ JP fir CORPORATION 0# PARTNERSHIP❑.# LLC❑#
COMPANY NAME s ( Dd`4 Plum 441 /Pa ADDRESS 7Dse'Pr/'Y Ori
CITY /1rSforl ,72,//5 �/ STATE,/27 , ZIP O26q TEL gbk-Te/oW 66/Z-
FAX CELL EMAIL ye (-w<' 191--/ o2 3 a7aA0G . Car,
.4Agni:
ROUGH PLUMBING INSPECTION NOTES )3ELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 ❑
e0//-Z/ /V-e' 07-C FEE: $ PERMIT it ! V l ✓ /i"7
VVV PLAN REVIEW NOTES
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