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` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
.MI_- CITY ( D11 :/G /MMA DATE /Dv �D( ( PERMIT# I/L�'i�/D�'®Q�/
JOBSITE ADDRESS '��i4j / % f ('7 4.7' OWNER'S NAME C?' i '.&' (u-
POWNER ADDRESS G' TEL- ' 2 6--OM FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[ -
CLEARLY NEW:0. RENOVATION:❑ REPLACEMENT:[6- ----...
PLANS SUBMITTED: YES❑ NO f----
FIXTURES 7 FLOOR—+ BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14
BATHTUB _ _
CROSS CONNECTION DEVICE "
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM . •
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER Sl, .
DRINKING FOUNTAIN
FOOD DISPOSER ' .1
FLOOR/AREA DRAIN .
INTERCEPTOR(INTERIOR)
KITCHEN SINK -
i LAVATORY _ .__.
Ft E1. V, 11
ROOF DRAIN �-- -I
SHOWER STALL �
i SERVICE/MOP SINK at if -
TOILET .....,_.._.
URINAL k u LUI'v OF,,A,,
WASHING MACHINE CONNECTION f_ `)' ---- —r--
WATER HEATER ALL TYPES yC
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 11.1r NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY CV-
OTHER TYPE OF INDEMNITY 0 BOND 0
i OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
1e Massachusetts General Laws,and that my signature on this permit application waives this requirement.
`. CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
l I I hereby certify that all of the details and information I have submitted or entered regarding this application are true an to to the b f my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complia all Perlin ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME 9Aal-te 4�-�SG1" LICENSE# 1S.2 ?' SIGNATURE
MP[I/r JP 0 CORPORATION 0# PARTNERSHIP❑.# ��� LLC 0#
COMPANY NAME TY/..;f*rieertneY' SeriCP ADDRESS 4R/ / �JA(ti c'`"((CITY,CC�C..� STATE /Ha ZIP 6126 3 I TEL •D 4
FAX 2, �(12 CELL5 V23' 'OS EMAIL $ f22SOe4--57-g �1 ^
c kL 10
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ 0 Frn//t-r-- 0/7-
FEE: $ PERMIT# /\97T /0Z OP
PLAN REVIEW NOTES
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