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MASSACHUS L .,k� `ETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK,,CITYo1)fi� MA DATE 3/d OZ
�1 6\ PERMIT#/OP/?-00 .
JOBSITE ADDRESS Q ,\I S OWNERS NAME Toin 2-
OWNER ADDRESS 76 l TEL 7)9 qq q d414 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL1
PRINT
CLEARLY NEW:❑ RENOVATION:QE REPLACEMENT:❑ PLANS SUBMI I I ED: YES ❑ NO❑
FIXTURES Z FLOOR—, 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 L' LP 1
LAVATORY s r it 0
ROOF DRAIN
SHOWER STALL 1 MAN 1 i 0 014 •
SERVICE/MOP SINK
I
TOILET AO
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 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 0
OWNER'S INSURANCE WAIVER:I am are that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and a signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER IX AGENT ❑
SIG AT OF 0 NER OR AGENT
I hereby certify that of e details and information I have submitted or entered regarding this application are true and accur to best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance wi II me is o the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME LICENSE#3?,14 Q . SIGNA RE
MP ❑ JP (( CORPORATION❑# PARTNERSHIP 0. LLC❑#
COMPANY NAME et o il,A5 ADDRESS 6 3 (oo)l� k c
CITY c STATE W1 k' ZIP 1 66 TEL 5b6 a3-) 36'99
FAX CELL EMAIL V1 V(I+ 0 'I _ �d0 t CGS
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
(Pa* O � THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
7 /� FEE: $ PERMIT# rf
77Y PLAN REVIEW NOTES
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