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MASSACHU ETTS UNIFORM PPLICATION FOR PE IT TO PERFORM PLUMBING WORK
-.1 CITY .J/� a rill MA DATE Z PERMIT#yt_D -2�1'ZSc-
JOBSITE ADDRESS ZrC1/r=c9/ril -- OWNERS NAME 1 .44✓1 d JL
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIALk_
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:® SEA ZC PLANS SUBMITTED:YES k NO❑
FIXTURES 1 FLOOR-, BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM --
DEDICATED GAS/OIL/SAND SYSTEM _ —
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM _
DEDICATED WATER RECYCLE SYSTEM -
DISHWASHER • --
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN -
INTERCEPTOR(INTERIOR) - —
KITCHEN SINK —
LAVATORY •
ROOF DRAIN
SHOWER STALL _• E � Fl D
SERVICE/MOP SINK
TOILET - wN h 12go2'Y j '
URINAL
WASHING MACHINE CONNECTION R p4,nEr'/R r .n
WATER HEATER ALL TYPES / By
WATER PIPING _ �_
OTHER S.ei°TIC TIP-//1 /
I -
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES g NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY A OTHER TYPE OF INDEMNITY 0 BOND❑
OWNERS 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 0 AGENT❑
SIGNATURE OF OWNER OR AGENT
41 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,ff is appl tion II be in compliance withal Pertinent provision of the
Massachusetts State P mbin?�Codel! and/tChapter
r1142 of th enperal Laws./� L
PLUMBERS NAM �c"kC`PL/R v` r LIC/ENNSFE## • SIGNATURE
MP❑ JP CORPORAT ON # ( CO p PARTNERSHIP[ , LLC❑l#j/�
COMPANY NAME ` ,`_3 4 t P ADDRESS �.7 �6LI(`.2 " " �}
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CITY ( - ' 7 GL n '1' c STATE ,'7YU ZIP 0 tp d � TEL , ,'2?
FAX CELL EMAILS4--r rn t2P-Ch CBC'ig-P09L5MltIL• ( 5M
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT
FEE: $ PERMIT #
PLAN REVIEW NOTES