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JOBS(( ADDRESS iter `Lllt'/� OWNERS NAME /D&
IPOWNER ADDRESS TEL FAX /
leit TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL IIS'
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CLEARLY NEW:0 RENOVATION:EII REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO ❑
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FIXTURES 1 FLOOR•+ BSMT 1 2 3 I 4 I 5 6 17 18 9 10 11 12 13 14
BATHTUB I I I I 1
CROSS CONNECTION DEVICE I I I
DEDICATED SPECIAL WASTE SYS I I II
DEDICATED GAS/OIL/SAND SYS I I 1
DEDICATED GREASE SYS I f _1
I1�, DEDICATD GRAY WATER SYS \
DEDICATED WATER RECYCLE SYS IKI I i 1IDRINKING FOUNTAINI \' I
DISHWASHER I fr
cI ( tFOOD DISPOSER I I \U1 •FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) ( I I I I
KITCHEN SINK I / f I 1= Ir. Xu `i iz [ f
LAVATORY.... / I I — 1 1 F '
ROOF DRAIN"- I I. 1 I - I
SHOWER SIAL 17 I I sr 213 20n1
• SEURVICE/MOP SINK • I 1
TOILET - lit n - �P ,,,iii
I ry: -- -61
WASHING MACHINE CONNECTION I I I yi{I�} W
WATER HEATER ALL TYPES / I I I I /4"
WATER PIPING II I I I I I I I 1
OTHER
I F 1 I I I
• INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalentwhich,meets the requirements of MGL Ch.142. Yes No❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [5 OTHER TYPE OF INDEMNITY 0 BOND ❑
OWNER'S INSURANCE WAVER 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 0 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 perm' Issued for this application will be In
compliance with II Perti nt provis' n of the Massachusetts State Plumbing Code aapter of the General Laws.
PLUMBER NAME fr✓t —v/4 •
`SIGNATURE " v!�'
LIC# MP 1 JP 0O� c,o liK 0 3 C I PARTNERSHI fp]# ,' LLC ❑#
COMPANY NAME C/ n r cn17 M 4
40 CITY ✓�2�n�,��-, /u STATE ZIP ( J ZMAIL Cef41 lilt 3 7 a Ali 1 i r
TEL 5�° '2-50#27n 27f CELL FAX
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