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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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JOBSITE ADDRESS 2 1 0 r y/-ia f ! OWNER'S NAM Cc C)
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TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
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CLEARLY NEW:❑ RENOVATION: f'REPLACEMENT:(a PLANS SUBMITTED: YES 0 NOD
FIXTURES Z FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
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_DEDICATED SPECIAL WASTE SYSTEM mannumumwmounn
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DEDICATED GAS/OIUSAND SYSTEMRm.=° __i___, _ ._ ,'..,.,..._... milimin
DEDICATED GREASE SYSTEM u
DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM ��_ �1.0!
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DISHWASHER S rliii '1111 ,01.111.111',Mi
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DRINKING FOUNTAIN .5 alin i - �_
FOOD DISPOSERAA _ Lam' `- KW1 ---i--_,
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) romiWINNIWIIIIItallillifflmlist
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LAVATORY ������',r y 1111111111.. 111.11.1116.11
ROOF DRAIN
SHOWER STALL Ih ,
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URINAL '_,_ ��� i � -'. -
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WASHING MACHINE CONNECTION �[ ;, _11. .' .._ _, 'Mi .. I
WATER HEATER ALL TYPES 1 . . _ 1_. - ,India
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WATER PIPING � - i � i� � -- � "'
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• INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES® NO 0 _
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY 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 •
I hereby certify that all of the detals 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 with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. J --�+ n (1
-PLUMBER'S NAME i • �11, `'p `--)a
r 1 Q I LICENSE#J 14_T/ I \ i, l SIGNATURE
MP JP ( / VC 5 I - / CORPORATION❑# dr-o P PARTNERSHIP❑#, 1LLC❑#
COMPANY NAME A (1)-,,, P1-t+ ADDRESS c' � C1377 7)r/Vie
CffY U\J . A rill 01/f /' !STATE (M I ZIP d ZCO 7-S I TEL 7 7 V 776 9/z
FAX CELL 1 EMAIL 1 • /be J• •,/Nt‘C—IS!`t Jo (D, 9 0-‘.4-// < n nz I
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ Ji!�F y/- C'(
/9i FEE: $ PERMIT# / �
G � F// j'LAN REVIEW NOTES
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