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MASSACHUSETTS UNIFORM AP PUCATION FORA PERMIT TO PERFORM PLUMBING WORK
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• CITY [r.te-t.--o c- I t f�MA. DATE /0 - 34' - / 3 PERMIT# /"i/� °2917
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JOBSITE ADDRESS 136 Lot ID k-a r s 1"`7E4 OWNERS NAME Q Co,,yr .o 1 /
p OVVNER ADDRESS Sc. ko ---P TEL FAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL EDUCATIONAL ❑ RESIDENTIAVI
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMI ISD: YES 0 NO 0
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FIXTURES 1 FLOOR-. I BSMT 11 2 3 1 4 5 I b I 7 I 8 9 10 I 11 I 12 1 13 I 14
BATHTUB I I I
CROSS CONNECTION DEVICE I I
DEDICA i cD SPECIAL WASTE SYS I I I —
DEDICA i rD GAS/OILISAND SYS I I
DEDICATED GREASE SYS
DEDICATD GRAY WATER SYS I I I I -
DEDICATED WATER RECYCLE SYS I I
DRINKING FOUNTAIN I I I I
DISHWASHER I I I I
FOOD DISPOSER I I I I I I
FLOOR/AREA DRAIN I I I
INTERCEPTOR(INTERIOR) I I I I I
KITCHEN SINK I I I I I I
LAVATORY...
ROOFDRAIM" I I I I I I
SHOWER STALL I I I I
SERVICE I MOP SINK • I I ITOILET II I Ir I I I
URINAL I I I I • I I 1 I
WASHING MACHINE CONNECTION I I I I I I I I
WATER HEATER ALL TYPES
WATER PIPING fi 1 I I I I I I
OTHER JJI I
-Il I 1 I I I
I I I I I
• - INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalentwhich,meets the requirements of MGL Ch.142. Yeit1 No 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICt+ 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 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 II Pertinentnprovision of the Massachusetts State Plumbing Code hapter 142 of the General Laws.
4.
PLUMBER NAME ( lira ti ti ,,,,-Pti. SIGNATURE U -p----:?.. s C --
C )-5 j ? -. MP❑ Al �RPORATION ❑# PARTNERSHIP ❑# LLC 0#
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C] cr, _ Z - •.DRESS: V? �-A? corLaa ! yr
���4 CO P�ANYNAME .:. c _ _ a I I `?
_''I_1 N CM 'I.DN-Lo c.-os -A r STATE VIA Zit .1 EMAIL
19i p 1R5-7Cal_ . FAX
C l � 11 -
La) Z° I.
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iNSPCCTiON
••• ROUGH PLUMBING INSPECTION NOTES THIS PAGE FOR iNSPCCTOR USE ONLFINAL NOT1;SY
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 ❑
FEE: $ PERMIT It
PI AN REVWW NUT.
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