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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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PERMIT# P IS ce973
' JOBSITE ADDRESS TTR C5-4,50-ex R 04.1) I OWNER'S NAME ra -51�i n S C. M(V`r 7 I '
P .OWNER ADDRESS 2 6OB t. LO fl CT r% /)rllie I TELV•393`1Y6 Pk (FAX
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TYPE OR OCCUPANCY TYPE COMMERCIALLIEDUCATIONAL D RESIDENTIAL® ,
PRINT
CLEARLY NEW:CI RENOVATION:41 REPLACEMENT:0 PLANS SUBMITTED: YES 21 NOD
FIXTURES I, FLOOR-. BUM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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CROSS CONNECTION DEVICE 'I 1, I. i _ 1
BATHTUB
DEDICATED SPECIAL WASTE SYSTEM IL_ - _- _- _
_DEDICATED GAS/011../SAND SYSTEMy is
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DEDICATED GREASE SYSTEM _
DEDICATED
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DEDICATED WATER RECYCLE SYSTEM • S . S
DISHWASHER
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oar- r -, .—� �- I J
DRINKING FOUNTAIN T JIMa
FOOD DISPOSER _L�.��� ��=�� r I , I
FLOOR/AREA DRAIN . .I 1
, INTERCEPTOR(INTERIOR) (i � '' I h( - _ (
I KITCHEN SINK (/aA T ) _ J.
LAVATORY �_
ROOF DRAIN
SHOWER STALL I * -
SERVICE IMOP SINK ;Polk 55S.� Z�
TOILET '► '" _
URINAL —„� .MIN '� �:�
WASHING MACHINE CONNECTION j,5 IS• II _ . ,_ - _. f
WATER HEATEPIPING ALL TYPES >�- ;i4 ��,{ � JI�11*G ^ «I
WATER PIPING � _ j'I ��� I i�A �iwrt' II
OTHER 15
• INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES 6 NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY®. OTHER TYPE OF INDEMNITY 0 BOND ❑ •
•
OWNER'S INSURANCE WAVER: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 walves this requirement.
CHECK ONE ONLY: OWNER D AGENT ❑
SIGNATURE OF OWNER OR AGENT ' •
1 hereby certify that all of the detabs and Information I have submitted or entered regarding this application are true and accurate to the best of my4mowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be N compliance with a8 Pertinent provision of the
Massachusetts State Plumbing Code" and Chapter� 142of the General Laws. 2 c.C--,\ r
-PLUMBER'S NAME Nit, 'Ely 'r. 9'-Q I LICENSE# U7 : SIGNATURE •
MPD JpEgl Pro P 'n - CORPORATIONQ# • IPARTNERSHIPQ# (LLC 0# I
COMPANY NAME N\t C 1 C9J! P 4. I ADDRESS / �-f ((J PJ- C.
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CITYIS0 I4 fMO./t ISTATE VG ZIP 6-z4, W' I TEL h7Y /4 wee I
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FAX CFLI:i I EMAIL 3-4-11•5-er- /`-C_S r r c90 0-5 01.. 4- .-• Conn
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY •
FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT•
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❑ ❑
FEE: $ PERMIT# / / / 10 /Ai
ELAN REVIEW NOTES
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