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..7% zN. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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kt,-(,-k 1 CITY1721 T7/1&i %°7L' MA DATE 6/7.3 PERMIT# }/6— 7f/
JOBSITE ADDRESS //00 _/ILEk/see asecee OWNER'S NAME SEW deker ra L.
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P OWNER ADDRESS J-76 ,il&aBeS 'v�
f0,7-045 % TEL (,//z'G6-O'W9^FAAX
TYPE OR OCCUPANCY TYPE COIJMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL Liyafltz C./Ats
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CLEARLY NEW:0 RENOVATION:[3 REPLACEMENT:?J PLANS SUBMITTED: YES 0 NO C
FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
i BATHTUB
CROSS CONNECTION DEVICE ,q' at
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 I AREA DRAIN _
INTERCEPTOR(INTERIOR) _
KITCHEN SINK Ifl K rfp f. p p: p M
LAVATORY 1, Ci 'I
ROOF DRAIN `1
SHOWER STALL NM 1 ) 20 3
fSERVICE/MOP SINK .
TOILET - LC:Lu;rc.;OP'
URINAL ��-mow. .
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WASHING MACHINE CONNECTION
I WATER HEATER ALL TYPES eg
WATER PIPING _
OTHER
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INSURANCE COVERAGE:
I I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch,142, YES tr.NO 0
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IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW •
LIABILITY INSURANCE POLICY [y' 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
j Massachusetts General Laws,and that my signature on this permit application waives this requirement.
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CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
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 i
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER'S NAME /T/'r 4-0 x
ex 4 LICENSE# ?V3 1 SIGNATURE
MP['/ JP❑ /� CORPORATION 21111 0 8.3 PARTNERSHIP❑# n LLC❑##
COMPANY NAME Q.O c '- a out Y /YT G ADDRESS S ' S Srain 4 a SO--
CITY SRA D ocoee a __ STATEX1,1_ ZIP c,J8 3f TEL'? 79 -372 ` WI(
FAX CELL_ EMAIL
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