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DVP : PRAe6G : , M OM/MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIYTO PERFORM PLUMBING WORK
1: CRY C /-(Q'4/1�QLT I-I MA DATE Ftr-1 PERMIT#&-V L'CVO ,f``
JOBSITE ADDRESS I I (1 iJ rC2:7 1 IUG:r,- a)1. . OWNER'S NAME b,U,Ai 1 Gt r,I rAV;n, 1
P OWNER ADDRESS 1 TEL 4I3 53) - 6I3 IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ® RESIDENTIAL Of
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CLEARLY NEW:® RENOVATION: ' REPLACEMENT:® PLANS SUBMITTED: YES® NOD
FIXTURES 7. FLOOR-. BM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOIUSAND SYSTEM Reginliminninii
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DEDICATED GREASE SYSTEM II OM M II MIR II OM MI
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DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN INTERCEPTOR INTERIOR
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KITCHEN SINK 0 IllhI1II - iii
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TOILETLAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
P III URU
ASH1NG MACHINE CONNECTION
WATER PIPING _
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URINAL elinjaillan Mann
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[ NO Ei
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY® BOND
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 comptiunc with all 'n ro n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME KW. . ffl °Brij e- I LICENSE# 1 47 oa4 I SIGNATURE
MP gi JP 0 CORPORATION yi#oZ C,,JPARTNERSHIP®# !LLC o# _
COMPANY NAME -Et P ).Li . (ADDRESS )1 (7_,Oci' PGdl 1
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CITY W. \%tomr-it a•,.,}A STATE (y)A I ZIP 02 67 3 TEL
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FAX 4of're-:Cal CELL4o 3tA-37 EMAIL . it ► t I ‘-' j M r ►' E C E I V D
z2e AUG 0 h 2019
4 Q4 BUILDING DEPARTMENT
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