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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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0 JOBSITE ADDRESS 44 GENEVA ROAD OWNER'S NAME[CHERYL MATTESON
N. P NI OWNER ADDRESS SAME TEL 508-398-3759 'FAX I,_._
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:El RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES 0 NOD
I FIXTURES 1 FLOOR-0 BSM 1 1 2 3 4 5 6 7 8 9 10 11 1 12 1 13 14
BATHTUB
CROSS CONNECTION DEVICE '111.1118111111111 MIN MIR MI NMI NM IIIIIIIIMIIIIIIIIIMIIIIIIIWIIIIIIII
w DEDICATED SPECIAL WASTE SYSTEM 1 11111111111.1111101111.IIIIIIIION IIIIIII11111111OM
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DEDICATED GREASE SYSTEMSTEM
DEDICATED GRAY WATER SYSTEM MI 1 IMO MR MI NW NW �...
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN _: =VW[IM
_FOOD DISPOSER 1 SEM SIN iiii Mil=
FLOOR/AREA DRAIN _ MO MR _ 111111111_
INTERCEPTOR(INTERIOR) �
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LAVATORY II
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SHOWER STALL
SERVICE/MOP SINK ._. a ,_.r. IIIIIMIIIIIMIIIIINIIIINIIIII
TOILET
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WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES 1
WATER PIPING ,_ . . ... �_. _..
OTHER MINMEMEMIMI 1111111•1111111111111111
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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 Li NO Li
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY ® BOND Ei
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 El
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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. l
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PLUMBER'S NAME Frank W.Roderick LICENSE#21.24 SIGNATURE
MP 0 JP D CORPORATIONE J# 1762-CPARTNERSHIP #WI LLC®#
COMPANY NAME Rusty's Inc. ADDRESS 222 Mid-Tech Drive
CITY West Yarmouth STATE MA I ZIP 12,17.2_____I TEL 508-775-1303
FAX 508-771-9310 CELL EMAIL
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