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- MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM PLUMBING WORK
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. _ _.. JOBSITEADDRESS I.... 33- Saclovvn Ur: 10VOIER8NAME I-,�,LiSC fri.1i _._ .__.. .._ _. 1
OWNERADORESSI ISI IFAX:I '
OCCUPANCY TYPE COMATE ICTAL 0 EDUCATIONAL 0 TESIDBin t L
NEW:0 RENOVATIOPt 0 REPLACBENT:11 PIANS SUBMinED: irEs 0 NO❑
FDOJTRES 1 FLOORS- Seel 1 2 3 4 5 8 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONN DEVICE . -
DEDICATED SPECIAL WASTE SYS
i DEDICATED GAWK/SAW SYS
DEDICATED GREASE SYSTEM •
DEDICATED GRAY WATER SYS
DEDICATED WATER REUSE SYS -
DISHWASHER '
DRINKING FOUNTAIN . n'ti cp -
FOOD WASTE GRINDER N 1
ff dy. 4 ,
FLOOR/AREA DRAW /� '
INTERCEPTOR INTERIOR
EN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE 1NORSW(
TOW . .
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES - •
i WATER PPM
' • INSURANCE COVERAGE
I have a current Naha,'insurance policy a its substantial equivalent with meets the requhements d MGL Ch.142 YES 0 NO 0 •
• IT you have chedtedlla please indicate the typed coverage by cheddeg the appropriate boa baba
LIABILITY Y tAIDEPOLICY 0 OTHER TYPE UWUW 0 BOND 0
OWNER'S INSURANCEWAIVEItIanaware that the licensee dna ban the insurance ooreragerequiredbyChapter 142dthe .
Massachusetts General Laws,aid that mystratum on this penult appalls;Win this recukement
CHECK ONE ONLY: OWNER 0 AGENT ❑
' SIGNATURE OF OWER OR AGENT
I hereby certify Mat ell ol the details and Wareation I have eutotted(or entered)ragbagIhisapplicaioneretrueand :.. I bThe best dmy
Knowledge and that all plumbing work and ireblatlam petaled ander the penult issued tela.applicable WI with at Pertinent
provision d the Maaadaheells Stab Plumbing Code and Chapter 142 of the General Lan. Ar
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PUMMEL NAME j/ A n7cBc:da. jute Ea Tit a ' SK>r7ATURE
COMPAWYNAME: K¢ar:n fil CSC:de. Pon.4Hera anti ADDRESS1 Si brhosrJ' (OSA 1
C1Y: (A) %',Atm sl-In - STATE: ran ZAP. DA6T3 ,_F 60d1778-€954-31CEL.(- 6o)-77F -466 Itt5o$)so4-97B1EMM
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MASTER 21 .O URNEYIMN CICORPORATIQN Efa r 'T-fl PARTNERSHIP❑IT;iN)m WOMEN