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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
i '"'�76-4 CITY Ll , -\I ARmOtr�1 IMA DATE to tat I IZ PERMIT# /71
JOBSITE ADDRESS 0:81 £RfYtP 5-r I OWNER'SNAMEL34 5 RFAcry
P OWNER ADDRESS I I TELI50834I-$491 FAXI
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ID RESIDENTIAL
PRINT PLANS SUBMITTED: YES❑ NO®
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:
FIXTURES 7 FLOOR-P. BSM 1 1 2 3 4 1 5 6 1 7 8 9 10 11 12 13 I 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM i
DEDICATED GAS/OILISAND SYSTEM
DEDICATED GREASE SYSTEM ,
DEDICATED GRAY WATER SYSTEM '
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER _ I l j L.
DRINKING FOUNTAIN _
FOOD DISPOSER `
FLOOR IAREA DRAIN
�
INTERCEPTOR(INTERIOR) i
KITCHEN SINK
LAVATORY
ROOF DRAIN ,
SHOWER STALL ,
SERVICE I MOP SINK
TOILET _
URINAL 4 �
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES 1
�
WATER PIPING 11 I i I
OTHER R ,
r— ; I
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES,® NO 0 I
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW—
LIABILITY INSURANCE POLICY
OTHER TYPE OF INDEMNITY 0 BOND 0 RECEIVED
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage requird by 4? U i
Massachusetts General Laws,and that my signature on this permit application waivesIthis requirement. r 4I
CHECK ONE ONIfNILrOWNE$
SIGNATURE OF OWNER OR AGENT ey'
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 Dance with all nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME C14 g15 bR1GG5 LICENSE#I/a4O1 I SIGNATURE
MP® JPA] CORPORATION®#I.3a3S IPARTNERSHIPD# ILLCD# I
COMPANY NAME BR ILC-5 it (-4Eino Pc4a ` ADDRESS I P.00 . 60 X 538
CITY I�Er1TERuicr.E (STATE ( IP- ZIP Oolfo3a TEL S6S-178-0816
FAX 775-0'10'7 CELL[ I EMAIL r brj h s @ GO I.com
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ 0
FEE: $ PERMIT# _
PLAN REVIEW NOTES
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