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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUM BIN
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JOBSITE ADDRESS f 2 3 ki✓;lww S-I- I OWNER'S NAMEL Awn i e,(ay
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TYPE OR OCCUPANCY TYPE COMMERCIAL I ) EDUCATIONAL ❑ RESIDENTIAL E✓
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CLEARLY NEW:❑ RENOVATION:[7i REPLACEMENT:❑ PLANS SUBMITTED: YES lil ,r]
FIXTURES 1 FLOOR-' BSM 1 2 3 4 5 6 7 8 9 10 11 12
BATHTUB
CROSS CONNECTION DEVICE I —ii�lINN lila—;-1� -
DEDICATED SPECIAL WASTE SYSTEM MIMII�4�iDEDICATED SPECI L A S SYSTEM ; I IIingignimini,
DEDICATED GREASE SYSTEM �,
DEDICATED GRAY WATER SYSTEM l DEDICATED WATER RECYCLE SYSTEM ' ill ill
DISHWASHER �" I ll _
DRINKING FOUNTAIN � ''��i!��:I��li��;�I !
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FOOD DISPOSER �lh���i
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FLOINTEOR
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FLOOR AREA DRAIN �_il _
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KITCHEN SINK l��i���; j(�1_ i=j
ROOF DRAIN �l
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LAVATORY i-- � �I�I�r- --li�!, imp
SHOWER STAL11111111111111111!1111111111111111111111111
!SERVICE/MOP SINK TOILET �- •
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WASHING MACHINE CONNECTION
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WATER HEATER ALL TYPES ,MM � � ' a ;- ISWATER PIPING I I �r I aar —rt41 7Ea �.OTHER) Rvl�r Conk4h�� 1 1: '
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INSURANCE COVERAGE: I ..
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ,/X NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ❑
LIABILITY INSURANCE POLICY d OTHER TYPE OF INDEMNITY ❑ BOND pi
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER El _
AGENT
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 with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER'S NAME
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SIGNATURE
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CORPORATION❑# PARTNERSHIP #
COMPANY NAME �' ��_ 1 LLC❑#L-_�
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CITY 5� f�'1�cvr rvw� I ----------------
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