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'!` t MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
= I CITY S. 74Pjrev '7'h._ — 1 MA DATE r/-t'//ie PERMIT# Mg- yes
JOBSITE ADDRESS a° j.jure _Y sy ,tT sQv i OWNERS NAME A.r;idc y 2c */y enk/bi di.
P OWNER ADDRESS Lab /3/erey yPd,'go/ ded _J TEL%./-4S/- cc,5 IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL C] RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION.' REPLACEMENT:❑ PUNS SUBMITTED: YES 9 NOE
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FIXTURES 1 FLOOR-. eat 1 2 3 4 5 6 7 8 9 10 11 12 ' 13 14
BATHTUB I - r
CROSS CONNECTION DEVICE _
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OILJSAND SYSTEM r
DEDICATED GREASE SYSTEM •
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER .
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK I' _
LAVATORY ( '
ROOF DRAIN
SHOWER STALL J^ -
SERVICE I MOP SINK J�_-- -e - ;1,/ 1- J1
TOILET 3 I • ----* ~I
URINAL 1 - ` It
WASHING MACHINE CONNECTION / eI Q') Ly Is
WATER HEATER ALL TYPES / y' .•.‘
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WATER PIPING / ' -/N-J )J I,-<TM N I
OT `,rre/ 172 orn-T'ir✓'-1 / . BO. pppdd \ _
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES X NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY! 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)valve%this requirement.
CHECK ONE ONLY: OWNER lat AGENT ❑
sGPWTLFE CF OANER CR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and acwrate to the best of my knoMedge
and that all plumbing work and Installations performed under the permit Issued for this application will be in•• fiance all P- ' :. provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �� I -
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