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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY tr7cavii'r� . 1 MA DATE /0.3e. /.c/ PERMIT# Y //-LV"4S1b . V5
JOBSITE ADDRESS 3 y 7 Pin,,,,S 6, u.q1/ OWNERS NAME —`ejlL,t y,,
POWNER ADDRESS S9,n, __ TELgot- 24o 3 i20IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL Q RESIDENTIAL j3
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Eke PLANS SUBMITTED: YES Q NO❑
FIXTURES 2 FLOOR-, 135M 1 2 3 4 5 6 7 8 9 10 l 11 12 13 14
BATHTUB ry iit
CROSS CONNECTION DEVICE ( ..--'
DEDICATED SPECIAL WASTE SYSTEM _ III �1
DEDICATED GAS/OILISAND SYSTEM '
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM • i J ii_ _,
DISHWASHER --- `
DRINKING FOUNTAIN i j,
FOOD DISPOSER
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FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN I
SHOWER STALL „,J
SERVICE IMOP SINK ( I il
TOILET
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URINAL
WASHING MACHINE CONNECTION t I
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WATERHEATERAL/L, •ES
WATER PIPING LY 7 to ;, r _
OTHER nn7 n i nn11. _ I
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v'�` INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES p NO U
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POLICY ge OTHER TYPE OF INDEMNITY Q BOND Q
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 waives this requirement.
CHECK ONE ONLY: OWNER Q AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance withaa ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER'S NAME If /s*rlpJie( PIe'ScJi&r LICENSE# /5737 SIGNATURE
MPD JP El CORPORATIONNil 32,45 ? IPARTNERSHIP❑#I LLC Q#
COMPANY NAME A}lq ? PIQ L.J ADDRESS I F-913aaclec-/J- eel
CITY EeSri4TA., ISTATEttnR LPI UJ ham! TEL zcr 3 6 3 h
FAX CELL EMAIL ! 1
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