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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
1-1,110::= CITY _ . 4 4 nli / MA DATE L )/S7/3, -_ PERMIT# PJ3 - 7f
JOBSITE ADDRESS ' • `g x7 c.y lg J OWNER'S NAMEy . Ja„I-2./J K_..
OWNERADDRESS _ �� FAx
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL D RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:[] REPLACEMENTCI PLANS SUBMITTED: YES 0 Nag_'
FIXTURES 1 FLOOR-. BSN 1 2 3 4 5 8 7 8 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 I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK ,
LAVATORY
ROOF DRAIN
SHOWER STALL --
SERVICE I MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES R. NO
IF YOU CHECKED YES,PLEASE INDICATE THE'TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND[l
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 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and irfamatian I have submitted or entered regarding this application are hue accurate to the best of my knowledge
and that all plumbing work and installations perfomied under the pertNt issued fortis application wN beEafrair • of the
Massachusetts State Plumbing Code and Chapter 142 oftheGeneral Laws. ,WS
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PLUMBER'S NAME I� �t� �J�(1/, YW;,, , !LICENSE# 1070r _ SIGNATURE
MP kl JP❑Q CORPORATION❑#L : _jPARTNERSHIPfl#
COMPANYNAMME.c}Yiliots /Jsun 1/2 ?..-/_ I ADDRESS Liao x: 39_
CTTYlk ll STATE itipf
. .: ZIP I O 21,2_to 8. I TEL sgarip
CELL ft[.
FAX I EMAIL i
-,)I-"MAY 17 2013 -/
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