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��\\MA��//SSACHUSETTryNS//,,UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CnY ere r9O1 CI n Mk DATE //2 / . /.3 PERMIT# P/.7 " 1 ZG /
JOBS ADDRESS 54 d.5R I� �t4e9 GN OWNER'S NAME x , UCC.• I•' A'?
pOWNER ADDRESS_ TEL TEL FAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL Z3----
PRINT
CLEARLY NEW:0 RENOVATION:V REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
FIXTURES 7 FLOOR-• BSMT 11 2 3 4 5 6 17 18 19 10 I 11 12 I 13 14
BATHTUB
CROSS CONNECTION DEVICE I 1 I 1
DEDICATED SPECIAL WASTE SYS 1 1 1 1
DEDICATED GAS/OILISAND SYS I 1 1
DEDICATED GREASE SYS I I 1
DEDICATD GRAY WATER SYS I 1
DEDICATED WATER RECYCLE SYS
DRINKING FOUNTAIN 1_ _l _ -_I_.__) _ ___I ____.L.
DISHWASHER
FOOD DISPOSER
FLOOR f AREA DRAIN /J
INTERCEPTOR(INTERIOR) I I I .._� SfiS�� J
KITCHEN SINK
LAVATORY..-- I _ fTi/ty,17I ,✓
ROOF DRAIN. I C G/a vP
SHOWER STALL /
k SERVICE I MOP SINK
TOILET / I i I - I
URINAL
WASHING MACHINE CONNECTION I- / _ I 1
WATER HEATER ALL TYPES / I
WATER PIPING ' / I _
eTHER� Y INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which,meets the requirements of MGL Ch.142. YesNo 0
IF YOU CHECKED YES, PLEASE INDICATE TH TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
N.,,,.
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND 0
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 0 AGENT 0
AA Signature of Owner or Owner's Agent
1 I hereby certify that all of the details and information I have submitted(or entered) regarding this application are true and accurate to the
RI best of my Knowledge and that all plumbing work and installations performed un•- -- •--mit Issued for this application will be in
ST compliance with all Pertinent provision of Massachusetts State Plumbing C.•- and Chap rt e/ ra -ws.
`/ PLUMBER NAM � 6 NATURE #" �, 4/
LIC# 106,-3 MP yd- IP❑ �CORPORA11ION # PARTNE" HIP ❑# LLC ❑#
COMPANY NAMEOrilA-C�/ u L frt(cc•sitl ADDRESS: I15a7 �51�J-k- ViI1 J
CITY MA-5Id s Mill ll STATE M6 ZIP se,26/EM,JL' y1'l. 10 C23 0 /14S' / �d-r_
TEL 370 6- ' A/QJ g-3 sr CELL 370e- 337-2DC8 AXE , p .
LI- APR 24 2013 --)
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