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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO DO PLUMBING
Cc_=`a+'= ' CITY/TOWN:I Mr.-e r,L(!?`h?-r--
. y I APPLICATION DATE: 7-ZZ- "
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= JOB ADDRESS:I 'y9 rie e7 ',..? ..3
PLANS SUBMITTED: YESO N0rn
POCCUPANCY TYPE: COMMERCIALE] RESIDENTIAL
NEW 0 ALTERATION REPLACEMENT® REMOVAL/DEMOLMOND
C PLUMBING: PIPING-FIXTURES-FIXED APPLIANCES-APPURTENANCES 1
ENTER TOTAL AMOUNT FOR EACH SELECTION(LIMITED TO FIVE(5}NUMERALS
ALTERNATIVE TECHNOLOGY 1 DISPOSER 1 SINK: MOPU SERVICE U_
rat
ASPIRATOR DRINKING FOUNTAIN STERILIZER
DRAIN: AREA) I FLOOR(-{l EJECTOR n STORAGE TANK
BACKWATER VALVE ',• =m1 EMBALMING ) I AUTOPSY I ( - URINAL
BAPTISM:FONTU SACRARIUM U �� FOOD CHEST MISTING SYSTEM VACUUM DRAINAGE SYSTEM
BAR SINK GLASS WASHER WATER CLOSET
BATHTUB' I WHIRLPOOL' I L..... ICE MAKER WATER HEATER:ALL TYPES ' /
BIDET INTERCEPTOR:ALL INTERIOR WATER PIPING:
CROSS CONNECTION DEVICEeaKITCHENSINK -_^ f OTHER NOT LISTED 1
DEDICATED: ACID WASTE SYSTEM LAUNDRY CONNECTION
DEDICATED: GAS/OIL/SAND SYSTEM LAVATORY rev
DEDICATED: GREASE SYSTEM PIPE RELINING WORK ONLY m.,
DEDICATED:RECLAIMED WATER ROOF DRAIN I
DENTAL FIXTURE I EQUIPMENT SINK: 1.2-3 BAY) PREP.
DISHWASHER SINK:CLINIC fl FLUSH RIM H f
((�� PLUMBING INSTALLER-FIRM-COMPANY INFORMATION- CHECK ONE ONLY
NAME:L%�ain,4 /ttt 1 ADDRESS:I� --; a—s'W"f �" -1 ❑C°rp°ratlan Business! I
CITY: ." " . !STATE: - ZIP: "Z641� OPartnership Business/l
TEL I FAX:I EMAIL: rV I ❑LLC Businessli
[3DBA I Unincorporated
NAME OF LICENSED PLUMBER: j2,,, ' fri. AreCtif
INSURANCE COVERAGE
I have a current liability Insurance policy or,its substantial equivalent,which meets the requirements of MGL Ch.142 YES NO D
If you have checked Yei,please indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy 0' Other type of indemnity 0 Bond 0
OWNER'S INSURANCE WAVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General taws,
and that my signature on this permk application g's this requirement.
CHECK ONE ONLY
Signature of Owner or Owner's AgINtt -_,_^-y OU AGENT❑
OWNER'S NAME:I ��-TEL:1-------1 FAX: I
I hereby certify that all of the details and information I have submitted(or entered)regarding this permit application is Ins 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 the General Laws.
USE ONLY) TYPE OF LICENSF�:
Permit/C 2_ 0plumber �oN` '• '
�p� A Signature of Lie d Plumber
Inspector0":'- `.ati [Master 6 V J
, 9 0
Fee:U ❑Journeyman I1 sr yb l"'I/ w
' JUL 2 2 2011
CUILDING DEPT •
By
ROUGH PLUMBING INSPECTION NOTES
BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ •
S PERMIT It
i
PLAN REVIEW NOTES t