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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
1/4,4_
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=1--'` y'9 MA DATE /1— 2G_/c! PERMIT#/ j - ' 2_,
JOBSFIE ADDRESS $' Cl F2 C u i T /Q Q /(/- OWNER'S NAME /11 R Roy 0 . 14 LiPri I P
POWNER ADDRESS C.;IZ C v t T I? 0 /1/ TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:D. RENOVATION:❑ REPLACEMENT: — PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7 FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB J }
CROSS CONNECTION DEVICE —
DEDICATED SPECIAL WASTE SYSTEM 1
DEDICATED GAS/OIL/SAND SYSTEM L
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
•
DEDICATED WATER RECYCLE SYSTEM
DISHWASHERi ,
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK v A,
LAVATORY (0 i N 3
ROOF DRAIN ,NS T_
SHOWER STALL
SERVICE/MOP SINK - t .;
TOILETi TY6F __URINAL _ I
WASHING MACHINE CONNECTION L
WATER HEATER ALL TYPES
WATER PIPING
OTHER /
1 [ , _
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 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
f Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT
1-1.I 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 compliance all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# 17 07 Y SIGNA 'E
MPIDJP' CORPORATION 0# PARTNERSHIP❑# LLC # P?1
COMPANY NAME ��/c‘olPG /= , TR/0 qva ADDRESS 2 v Pa 0S' --c7' � '-e
CITY (.v- )�2< STATE/-•57 • ZIP GP 2 6 7 5 TEL,5-70,9- Y22 - e;,/.es
FAX A/o ivre• CELL. 'O e-Y2 z - ell !'S EMAIL rt"oev-r A/e it
ROUGH PLUIYi>x
1NG INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES.
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ • PERMIT# /
PLAN REYIEW NOTES " / 47
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