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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
7 CITY 5,,,.th yarrro..tbl MA DATE 8fig 1t8 PERMIT# /OV-RAOOoro
JOBSITEADDRESS 35 Rskiim amok Aet. OWNER'SNAMEL Rnan.. 1). Caoke-swr
P OWNER ADDRESS 3S Fill+ tcoL Ai TEL -77q.Zvj•Zo7S^ FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT .
CLEARLY NEW:C:1tJ
RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOD
FIXTURES 7 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 11Iri ii 1 .r
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM r
DEDICATED GAS/OIL/SAND SYSTEM
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DEDICATED GREASE SYSTEM �_r
DEDICATED GRAY WATER SYSTEM 1 r r
-
DEDICATED WATER RECYCLE SYSTEM 1 1
DISHWASHER
ER _ _
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DRINKING FOUNTAIN
FOOD DISPOSER - I ' I
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FLOOR(AREA DRAIN i
INTERCEPTOR INTERIOR) - i, li �
KITCHEN SINK i j I I 1I
LAVATORY ) r ' ir r -1 I
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ROOF DRAIN 1 r— i- D. II- P
SHOWER STALL
SERVICE/MOP SINK i r I. - ��-
WASHING MACHINE CONNECTION ' Ir - in ,S. I - t
TOILET _
URINAL _
WATER HEATER ALL TYPES r -, �r 81 iILDI .G 01 APoI AEN1 f
WATER PIPING r Iit lir — ',E _,
OTHER [ ,.I I_ 1 iI' ( I
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INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES[J(NO ❑
IF YOU CHECKED YES,PLEASE INDICATE T E TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POUCY[ OTHER TYPE OF INDEMNITY ❑ 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 ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR 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 of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'SNAMEI 8rices_Q. O..uurm LICENSE# /6/19 • SIGNATURE
MPR" JPO CORPORATION PARTNERSHIP❑#I ILLC❑#
COMPANY NAME[Ca PG.,nbu...,0syvr'rci (ADDRESS 3S Pts tarty g,k. ,dc(.
CITY 50 q .„4.t _j STATE L_a4 J ZIP 0246 N 1 TEL r
FAX I ___I CELL LN•Zlt_ZoviEMAIL L 8DCL-!SN fa Gac.•.i/• cowl___ __ — ]
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