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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
te CITY *G(101W 14 Mk
DATE f- r'9-/3 nP,ERMIT# /Q� —yir
JOBSITE ADDRESS 7r7 _diel/C 0 AZ OWNER'S NAME &t'O/ it/(4014./ 014.
POWNER ADDRESS S / .Lfhi /` z TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL EL'
PRINT
CLEARLY NEW:❑ RENOVATION:p' REPLACEMENT:ElPLANS SUBMITTED: YES❑ NO ❑
FIXTURES 1 FLOOR-. BSMT 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYS
DEDICATED GAS/OIL/SAND SYS
DEDICATED GREASE SYS
DEDICATD GRAY WATER SYS
DEDICATED WATER RECYCLE SYS
DRINKING FOUNTAIN
DISHWASHER
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK t/
LAVATORY t/
ROOF DRAIN
SHOWER STALL ✓
SERVICE 1 MOP SINK
TOILET A
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 tG No 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Er OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:lam 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 permit issued for this application will be In
compliance with all P In provision of the Mass chusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER NAME 1 tify �ICGTIC/ / �I ,/ SIGNATURE
LIC# (Jc2..Q' MPI Pit/M-01
0 t CORPORATION Lys NW PARTNERSHIPCNIP ❑�#// p�J LLC ❑#
COMPANY ' E Lela(' I `t/WLO1419 ��//JJAp ADDRESS: /4� /V S. / ft/r4 (J r r
CIN /L STATE/%A. zip dOJJe EMAIL f/n'47049f/MS/,29/Vie fret%ZG1. tuf
TEL n F ' &O CELIfrOf) pa-- c .cr/ f Tr -• y ;!,
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292013 D ,
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ROUGH PLUMBING INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
PLO C c211- c// 4(3 Yes No itp —UA– — y/7s7 .9
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ „OA,
FEE: $ PERMIT#
PLAN REVIEW NOTES