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orlSr 1/4/9 /91.07) 17— X7/7
MASSACHUSETTSUNIFORMAPPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY /PI 4- 0 fl MA DATE b 4 7 PERMIT# l 7-oo rz?d
JOBSITEADDRESS y d liliC Si lea- re 2/ OWNER'S NAME 64/4 egj t. '0' "r A
OWNER ADDRESS ,/ TEL C(7 0 4 2-482 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:Ly REPLACEMENT:V PLANS SUBMITTED: YES 0 NO 0 •
FIXTURES 2 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 •14
_
BATHTUB /., • .
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM _
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM _
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER _
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK L. ' •;
LAVATORY / i •
1
ROOF DRAIN JUN ��
SHOWER STALL •
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SERVICE I MOP SINK
TOILET ; CAS
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 0 NO 0
IF YOU CHECKED YES, PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY 0 OTHER TYPE OF INDEMNITY 0 BOND 0
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OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
t Massachusetts GeneralraLaws,Las,and that my signature on this permit application waives this requirement.
•
'Z v e /"�C l'Cr✓ CHECK ONE ONLY: OWNER E AGENT 0
SIGNATURE OF OWNER OR AGENT
LI 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 compile ce with II Fedi ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. '
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PLUMBER'S NAME LICENSE#SM/7 SIG E
MP❑ JP vCORPORATION❑# PARTNERSHIP❑.# LLC❑# )
COMPANY NAME ti//77Av r/1/96- ADDRESS 3 / f2Frc n/ CV grid •
CITY 4:3311 Pbrer r STATE(� /"'b ZIP 0>77: TEL
FAX CELL Sfl 8�I OMrW7 EMAIL Pi/6<°30 An /•
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