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1 <;`\ MASSACFIUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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: CITY I ! {'y IA,`-�� P�1.A DATE j I PERMIT n/%��/'-�9- J 07
JOBSITE ADDRESS ? OWNER'S NAMES S' r r r
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OWNER ADDRESS i � l�C)�I' (�11 1 /� .) P TEL J ]FA i
TYPE OR OCCUPANCY TYPE COMMERCIAL 7.7 EDUCATIONAL ' I RESIDENTIAL;
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CLEARLY NEW:[ 1 RENOVATION:Li:' REPL ACEMENT: PLANS SUBMITTED: YE S E NO I
FIXTURES Ti. FLOOR-4 BSM 1 2 3 I 4 i 5 6 7 8 9 10 11 -? 13 14
BATHTUB [��11T _1I 1I1.. 1.._, i1 _.. fi i( 1 'll I1 .. it it ? 1
CROSS CONNECTION DEVICE 1 . •_. 1- l , ,f. 't1.-_.. li .. .... li- t r-71_. ,.•I r • !) 711011,
DEDICATED SPECIAL WASTE SYSTEM It ...II _ill _;I_;IE- 3j—jr {i ..t[T-'If�:I. , .....IT
DEDICATED GAS/OIL/SAND SYSTEM 1 _11 1 11. 11.,..,. s1 ;I71,74. `II.. . 11,._...... i. ...... ,_
DEDICATED GREASE SYSTEM I I a. 11 TT1 1 r
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t;E.n!CATF^rRAY ifs' _° ;f 1 �fl 'H — T i——Jr—r— u I 3. ._ ll�-. � r I.-_�
DEDICATED WAT CAI ER SYSTEM t. ;k , i;.-.. ..,,.� d )I ji.. .. i..,.... 1i .i a
t ER RECYCLE SYSTEM j—� ;� I jJ.. lI ii !-1 .-11 11. i I`— -1 .. I
DISHWASHER II . _..II . . , i'--I ll -(I ...,_..Iii • ,1' -7
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DRINKING FOUNTAIN ;� i ..._._.Il. . . 1 — !II`7 .„ kr--71
FOOD DISPOSER r..—�` Ii . 11 '1 al ' , ,1 lll_ .. .....I ...._ .. . ... L .
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FLOOR!AREA DRAIN rVf! .. Il__. III I.... ... f.. . I .-- ' .,
INTERCEPTOR{INTERIOR} 1—I !H. ' ,.. .1, ... ...I !il_ 1 ..... ,I._..._ I '.I.. j
KITCHEN SINK ._._.!1i .. . I_ .... ;, I I r I. ... ;I_..... l _;... , i.. .. 1
LAVATORY 1 H 'I A j .. l� k .. I
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ROOF DRAIN '�i... .. a ) L...
SHOWER STALL Ii li.. 1 IL t • ;--7,1717 1
SERVICE'MOP SINK ! . .-7 1 - 17-7 _. f I j 1I_ U I —7I`--.1... ,.. I
TOILET 77771 11i... IFT °I . . II 11 1f,.... f` ii ' 1 .
URINAL i ` II ._ r---1 -tr;: _ - , I l
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WASHING MACHINE CONNECTION U .. ..._..'-mil 1.I ._ ! ._.., .. 11 _ I . 'I If.
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WATER HEATER AL TYPES �—,�r � I 1 � ';ll _ .i „t
WATER PIPING I 1 .li- "i .... .. ..k--I .,i—11._ _I 1- ;ice I:... :IL " . . .I.,.., t
OTHER :._It . 1a 1_.....__.. 1__ it 1 I 71 -'1. ._ i7_ 'iI Ili 'II ii `H �'7 71., __:-1
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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 I.�! J 7
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILIT` INSURANCE POLICY` OTHER TYPE OF INDEMNITY 171 BOND In
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of l he
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER E AGENT 0
SIGNATURE OF OWNER OR AGENT
l hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best c my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in,mpliance with all Pertinent prop.i i op of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. , � /,_O
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PLUMBER'S NAME Craig Bishop , _�—'�LICENSE# 15101 ? V SIGNATURE
MPE] JPf^ CORPORATION D#1 IIPARTNERSHIPE-1#7^I1LLCI 1__ _1
COMPANY NAME High Efficiency ADDRESS`378 Route 130 ;
, CITY I Sandwich a STATE Ma ZIP ,02563 TEL 508-825-3695
FAX 1 .1 CELL EMAIL 1 admin@high-efficiencyllc.com 1
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