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JOESITEADDRESS/SS" f34 r V P-i .41 ( F"-t - t OWNER'S NAME 5r.4p&tlrt I? , ft V
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er p OWNER ADDRESS /S5 (94y Li e tn.." s f?ECT TEL Str 17i - 19451 FAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED:i ED: YES 0 NO 0
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t FIXTURES 2 FLOOR-. BSMT 11 I 2 3 41378 9 10 l 11 I 12 13 I 14
N iL &4THTUB
GROSS CONNECTION DEVICE I I
t� r 'o DEDICATED SPECIAL WASTE SYS I I
a Ic DEDICAiEDGAS/OIL/SANDSYS I I
' I� ? DEDICATED GREASE SYS
DaDIC.ATD GRAY WATER SYS
▪ ' - DEDICATED WATER RECYCLE SYS
DRINKING FOUNTAIN I
DISHWASHER I
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) I
KITCHEN SINK I
LAVATORY..'.. I
ROOF DRAIN'"
SHOWER STALL I I I
SERVICE/MOP SINK •
TOILET I l
URINAL I I I I
WASHING MACHINE CONNECTION I I I I I I I
WATE72HEATER ALL TYPES
WATER PIPING
OTHER
I I I I I
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which,meets the requirements of MGL Ch.142. Yes 0 No 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY a.-- 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE BOX ONLY: OWNER ❑ AGENT 0 •
Signature of Owner or Owner's 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 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 th
PLUMBER NAME F&ns-c: 5 '3/4b Int( SIGNATURES
LIC# if S V 9 MP ad'JP❑ CORPORATION B#IS? 2- PARTNERSHIP ❑# LLC E-# s ,
COMPANY NAME •F g 4 Ar V .y I P P s N ;Inc ADDRESS: 0 .0 j X 6 Lu
CITY 4-- N 7 4'V.t,. S`l srr f STATE .ul d ZIP O .6 7 Z_EMAIL
TEL lb6 ?P /9 95-- CELL SDg' 73702_ FAX
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� INSPECTION NOTES
ROUGIE PLUMBING INSPECTION NOTES TUTS PAGE FOR INSPECTOR USE ONLY FINAL
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 ❑ .
FEE: $ PERMIT
PLAN REVIEW NOTES
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