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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY 6 r MA DATE I -if-I / PERMIT#*41 I `CJG 7/S
JOBSITE ADDRESS se, Ma- -^ n C�OWNER'S NAME otcx."14�
OWNER ADDRESS TEL /4133 7-YDZZZ FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAA
PRINT
CLEARLY NEW: ❑ RENOVATIONS REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO❑
FIXTURES 7. FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER _
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY jG x,
ROOF DRAIN c. ;}.
I SHOWER STALL >et
SERVICE/MOP SINK
TOILET. _ a t " r, i #
URINAL /` •
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES \—
WATER PIPING j4
OTHER
INSURANCE COVERAGE:
'.; I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES(cv 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 waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
L 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 c mpliance with all rtinent rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME LICENSE# 176 y/ SIGNATURE
MP ❑ JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME �CLo ,,
��'^"`�'/�,�en �� 6 ��{ ADDRESS
CITY (' Ny��IS ` -lam STAATE /_tc- ZIP OZ,rc)O1 TEL)7 7 6 (d 02
FAX 7)Yb 16 Ot`i Z
CELL EMAIL O e �►M b
C 117qo
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ 0 /12__6O C'
&./! &/! �? FEE: $ PERMIT# ��� Vfi
PLAN REVIEW NOTES