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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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sse_ ' lC'‘ 'Cc 3j?t'l \ MA DATE \X\70\\ 6 PERMIT#/3WP "�i2.S
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JOBSITE ADDRESS ?a.- • OWNER'S NAMECO(-CC\ •
o P . OWNER ADDRESS \1�(—'C CC1C cc Yl�9CC TEL FAX
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TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL 0 RESIDENTIAL-pi
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:$. PLANS SUBMITTED: YES 0 NO 0
FIXTURES 7 FLOOR-. BSM 1 2 3 4 5 6 7 6 9 10 '11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM _
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER •
FLOOR/AREA DRAIN •
INTERCEPTOR(INTERIOR)
KITCHEN SINK •
LAVATORY
ROOF DRAIN •
SHOWER STALL
SERVICE I MOP SINK
TOILET
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. YESja. NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY I`-'l 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 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application are twe 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 complia ith all Peril 'rovision 'f the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Curt S. RieCe11 LICENSE# $,?y(Q SI riTURE
MPE 'JP❑ CORPORATION 0# PARTNERSHIP❑# LLC❑#
COMPANY NAME Curl F. R ect ell t Son ADDRESS -77S Mc,in jfI-eat
CITY OStecvitle STATE MA ZIP 0aCo55 TEL 5O8' HaR- C_o3Co5
FAX CELL EMAIL
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