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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
e1gHl� CITY L.Je 54- / rry-)0 -I-& I MA DATE VA DO //. PERMIT# 6/ /C-Cd 519'7
JOBSITE ADDRESS DS JY)errl-'mQori`-- rT Q OWNER'S NAME rr-C2r rr,L,er4-S
P OWNER ADDRESS 1 TEL '78 I �35-U 53G FAX
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TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIA&EI
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:p PLANS SUBMITTED: YES❑ NO❑
FIXTURES Z FLOOR-• BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB .._ I.. _ _ ,y
CROSS CONNECTION DEVICE
i i / 'DEDICATED SPECIAL WASTE SYSTEM IJ I 0 ( ! I _ _ U { 1
DEDICATED GAS/OIL/SAND SYSTEM
I I $ - 1 - , .
DEDICATED GREASE SYSTEM .-
DEDICATED GRAY WATER SYSTEM • l - (( _ 4. I r Z. I _ J.
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DEDICATED WATER RECYCLE SYSTEM � - ___ 0_.-, . .. __I __ r mu. .\ I, -, J
DISHWASHER
DRINKING FOUNTAIN t .11 U 1 41 1
FOOD DISPOSER FLOOR t JJ i 1 I ,
INTERCEPTORERCEPTOR(INTERIOR) J , , ... __.
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•,,- --I- ,-.ti - • -1, ,li ,.., ffil 0.91'
KITCHEN SINK I f
LAVATORY
ROOF DRAIN , if .. 1 _ Iv.
SHOWER STALL
SERVICE/MOP SINK �
TOILET i w,.
URINAL ( Q U I U . - ,fr.
WASHING MACHINE CONNECTION u ��' I� _n _
_ [ t ..... -. ,-@+ • - �.., I F
WATER HEATER ALL TYPES �p • � ,
WATER PIPING ,.0 (II I 11
OTHER
_ 11 --AL
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
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.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR 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 corn . nce with all Pertinent pr ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME n Lp Sr-c_e S_ ,LICENSE# O J SI NA
MP11) JP❑ CORPORATION 0# PAR E LLC❑#
COMPANY NAME Se.if ADDRESS 153 £ i H-'`er Dr-,u'.
CITY J ,-)r);5 STATE MA.- I ZIP 0D6 3ce, TEL SDE-$ -66`I3
FAX CELL EMAIL .I.f411-4-ec_An;c,ct-iP...-(ovncoY -nel-
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
4 Yes No
THIS APPLICATION SE VES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
t
Y
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