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MASSACHUSETTS UNiF a RM APPLICATION FOR A PERMIT TO DO PLUMBING
`�+'_ ` CITY/TOWN: ' td /. �I �_._._.._.._.�. APPLICATION DATE: T/" 9A'-// 1
JOB ADDRESS: �a�,<�✓7iatea/
PUNS SUBMITTED: YESO N0://
POCCUPAJJCY TYPE: COMMERCI LEI RESIDENTIAL
NEW u ALTERATION REPLACEMENT 0 REMOVAUDEMOLTf1ONO
r PLUMBING: PIPING-FIXTURES-FIXED APPLIANCES-APPURTENANCES 2
ENTER TOTAL wow FOR EACH SELECTION(UNTO TO FIVE(5)NUMERALS
ALTERNATIVE TECHNOLOGY all DISPOSERSINK: MOPU SERVICEU
ASPIRATOR DRINKING FOUNTAIN STERILIZER
DRAIN: AREAL I FLOOR, I ' EJECTOR itt� STORAGE TANK
BACKWATER VALVE �j EMBALMING I I AUTOPSY I I I� URINAL F
BAPTISM:FONTI-I SACRARIUM n FOOD CHEST MISTING SYSTEM VACUUM DRAINAGE SYSTEM
BAR SINKGLASS WASHER ( WATER CLOSET
BATHTUB WHIRLPOOLI I MIMI1 ICE MAKER �� WATER HEATER:ALL TYPES i
BIDET INTERCEPTOR:ALL INTERIOR WATER PIPING: i /
CROSS CONNECTION DEVICE AMR KITCHEN SINK r p OTHER NOT LISTED 1
DEDICATED: ACID WASTE SYSTEMrJr�LAUNDRY CONNECTION
DEDICATED: GASIOILISAND SYSTEM �I LAVATORY
DEDICATED: GREASE SYSTEM I PIPE RELINING WORK ONLY
DEDICATED:RECLAIMED WATER SI ROOF DRAIN
DENTAL FIXTUREI EQUIPMENT ! SINK: 1-2.3 BAY, 1 PREP.
I
DISHWASHER /SS SINK:CLINIC I FLUSH RIM H
P i B. L. E• -Fi;u - au I O• Ti r CHECK ONE ONLY
NAME:r milts ADDRESS: a (,/,.L 7,. 444im OCorporaUGn Business it I
CRY: "' " " ir '`/ /T/--to STATE: ZIP:I 4r! :J J OPaMership Business it I
TEL: ( I I -1 EMAIL: Lamy Businessil I
FAX:
BA I Unincorporated
NAME OF LICENSED PLUMBER: •
INSURANCE COVERAGii
I have a current liability insu a policy or,its substantial equivalent,which meets the requirements of MGL Ch.142 YES NO O
If you have checked 12,pie indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy Other type of indemnity 0 Bond 0
OWNER'S INSURANCE WANEIt I am aware that the licensee donna have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,
and that my signature on this permk application waive this requirement.
CHECK ONE ONLY
Signature of Owner Or y�rSe-ry3�p�ejn�t - /
OWNER!: AGENT❑
OWNER'S NAME:r`/ / i lJ G ..____}TEL: I FAX:
I hereby certify that all of the details and Information I have submitted(or entered)regarding this permit application is true and accurate to
the best of my knowledge.I certify that all plumbing work and Installations performed under the permit issued,will be in compliance with
all pertinent provisions of the Massachusetts Uniform State Plumbing Code,and Chapter 142 of th • - . Laws.
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r ,./I 'future of Licens d Plumber
Inspector t tAN — Master ////
I a 0Joureyman License Number, ZL
Fee: I
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