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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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;jam CITY I MA DATE portall •ERS MT#_✓r
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JOBSITE ADDRESS 'Br '.S Gr A OW ER'S ''•MEW, , ,'3 Iii54 ,.f
POWNER ADDRESS TELVOI'%y'7/s ]JFAXI
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL t
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:® PLANS SUBMITTED: YES❑ NO®
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB I 1 1 i
CROSS CONNECTION DEVICE __ L
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/01L/SAND SYSTEM h r._
DEDICATED GREASE SYSTEM I
DEDICATED GRAY WATER SYSTEM _ jl ; - , ,,
DEDICATED WATER RECYCLE SYSTEM i, j -.
DISHWASHER •
DRINKING FOUNTAIN , j( I l i ,I • I ',-
FOOD DISPOSER I -Al l -, 1 i
FLOOR I AREA DRAIN S I
INTERCEPTOR(INTERIOR) i• yT r--11/-If ( r 1—
KITCHEN SINK
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LAVATORY ! /
ROOF DRAIN i
SHOWER STALL • �, •, ,I
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SERVICEIMOPSINK r . I ,
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TOILET •
URINAL
WASHING MACHINE CONNECTION •
WATER HEATER ALL I • . J
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fes. RTMENT INSURANCE COVERAGE:
hir• Witt it trlsur policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO
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I OU ECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Maetts General Laws, nd tha a ignature on 's permit application waives this requirement.
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' CHECK ONE ONLY: OWNER ►'I1 AGENT ❑
SIGNATUR OF OWNER OR AGENT
I here.y certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the b. t of my k,.wledge
and that all plumbing work and installations performed under the permit issued for this application will be in n• pliance with all Perti A 4rovisi. .f the
Massachusetts State Plumbing Code and Chapter 142 the General Laws. rte. — l / - ,/
PLUMBER'S NAME oict f; Rh LICENSE# MOM,, SIG AT E
MP� JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAM 3LA f f , ,_,, ADDRESS
1 96�' /_4ti .510,,A,„ RI
CITY STATE I/LA ,mow ZIP Qat1O6 TEL 'S ')5'$89' /6-R6 d
FAX !CELL EMAIL •
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