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MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM PLUMBING WORK
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4_5— YA(2--Yvv3vIM-1 7;)TE IO ( I / PERMIT# bP - ,2/.Qt
JOBSITE ADDRESS 9. LA r15/1-1G OWNER'S NAME WO V E •
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OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL(�
PRINT
CLEARLY NEW:❑. RENOVATION:2' REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR-4 BSIVI 1 2 3 4 5 6 7 8 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 •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK l
LAVATORY
ROOF DRAIN •
SHOWER STALL I
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SERVICE/MOP SINK
TOILET i
URINAL
. WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
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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
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IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY 12/ }t,
OTHER TYPE OF INDEMNITY ❑ BOND ❑ ,,y
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by1H 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
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CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
'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 comp'ance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME ,'r\ 013 3 E LICENSE# I 3 S7 SIGNATURE
MP El/ JP 0 CORPORATION 0# PARTNERSHIP❑.# LLC 0#
COMPANY NAME A O Q£ I4 ADDRESS S96 z A
CITY I-1-fRuJ\ci:+ STATE Y v ?1 ZIP O 6 `1,C TEL sag _36 2-6`l 3 7
FAX CELL EMAIL "136 E cI/ r l-Lmn Bi11G0- Cv;-✓10.45 j, iVE'T
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
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THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
‘_4771-- 77/72 ii FEE: $ PERMIT# fft/v/i fr-CP O' 1
PLAN REVIEW NOTES /o /•
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