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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
-=1 CITY 7f'/l? /�'C« MA DATE 1 :5 --1 -.2 PERMIT#, 41-7/ Z 3 //s IV
JOBS ADDRESS 627 4'/? _;�J OWNER'S NAME ,)i.1ct.✓1 Hot r i C I2g
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL r
PRINT
CLEARLY NEW:❑ RENOVATION:[l''- REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1. FLOOR-4 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE --_----
DEDICATED SPECIAL WASTE SYSTEM di
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEMgirliiriirMleiriaril
DEDICATED WATER RECYCLE SYSTEM 11.111111._---M jMrIN � ,� ,�►�►,�
DISHWASHERIII�■�■ • tarre7.111161111.1,11
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN all
INTERCEPTOR(INTERIOR)
KITCHEN SINK all
LAVATORY 1111111=' • 111111.1.1M11,11
ROOF DRAINSHOWER STALLSERVICE/MOP SINK
OILET
II
U URINAL
. WASHING MACHINE CONNECTIONWATER HEATER ALL TYPES ������ NWATER PIPING __
OTHERIIEI
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 2--NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND ❑ i
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
1' Massachusetts General Laws,and that my signature on this permit application waives this requirement.
T CHECK ONE ONLY: OWNER ❑ AGENT ❑
`<_ SIGNATURE OF OWNER OR AGENT
L',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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /�
.4-2-1-4-Z2;7 2- . `fir"
PLUMBER'S NAME /r /17 C Y'r,,.7 (-, -t
6' �- "' LICENSE#/174 'c''% SIGNA NJI
MP E2r- JP❑ CORPORATION eir _2 j 7 PARTNERSHIP❑.# LLC❑#
COMPANY NAME /I/aril -G-/,‘N', ADDRESS rr/ • /"'
CITY j s' /12 gSTATE, ZIP 02 7,J TEL
FAX
CELL` J'�-Q.3C z)/3 / EMAIL 17-e& -f',n./''26'C/ ' rC-