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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY I G MA DATE 3'7 a� ( PERMIT# P, ,(_u3 �r 94
JOBSITE ADDRESS U 3 �I I r `�� OWNER'S NAME RCA_ MC Lt5
pOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Er
PRINT
CLEARLY NEW:0 RENOVATION:ElREPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO 0
FIXTURES 1 FLOOR-6 BSMT 1 2 3 4 5 6 7 6 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYS
DEDICATED GASi01USAND SYS
DEDICATED GREASE SYS
DEDICATD GRAY WATER SYS
DEDICATED WATER RECYCLE SYS
DRINKING FOUNTAIN
DISHWASHER
FOOD DISPOSER
FLOOR!AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY .._
ROOF DRAIN._ -_
SHOWER STALL
SERVICE 1 MOP SINK
TOILET I
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING I ( y a Y
OTHER pU,01 Q09
gY. INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which,meets the requirements of MGL Ch.142. Yes4d'No❑
IF YOU CHECKED YES,PLEASE INDICATE TTHHE�A`PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
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
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 Pertinent provision of the Massachusetts State Plumbing Code an ter 142 f the General
PLUMBER NAME W 344-LI LA
• l LeMle / SIGNATURE ^ /W`✓'� ^ "V•- .iL
LIC# I MP Ly JP❑ CORPORATION ❑# PARTNERSHIP ❑# 1 LLC ❑# ////
COMPANY NAME r�•«�'U4`-` pl., ADDRESS: �'M. \�- IQ`A-�c-tCS IOUh.J
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CITY �1 QP V...t[S STATE /r C+• ZIP 6a 6 Q EMAIL." l.!����cvi��
TEL CELL Soy- le 457.-444S--- 1�-1 _ ye!
7114111.A0R ft/1219112011
°12'9 f 2091 I3
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BUILDING DEPT
ROUGH PLUMBING INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
• Yes No
THIS APPLICATION SERVES AS THE PERMIT .0 0
FEE: $ PERMIT#
PLAN REVIEW NOTES
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