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MASSAC/ M/1 / n HUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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,/' V 6 I MA.DATE /3 PERMIT#Q9cu�-24-213
� JOBSTTEADDRESS I/T PrA L� OC/44iL OWNER'SNAA )L—(/i P '1�-0.S �ou/
OWNER ADDRESS I 7)1 TB-1 50:45-A?/IFAx
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL. -
PFUNT
CL.EARLY NEW:❑ RENOVATION:❑ REPLACEMENT:t/ PLANS SUBMITTED:YES❑ NOEL
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 6 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRNIONG FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
/ITC SINK
LAVATORY
ROOF DRAIN
SHWER STALL _
SEROVICEI MOP SINK
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current)labllltv Insurance policy or Ks substantial equivalent which meets the requirements of MGL Ch.142. YES NO J.
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 WAVER:I am aware that the licensee t si 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 deteis and Information I have submitted or entered regarding this application am true and accurate to the best or my knowledge
and that all plumbing work and Installations performed under the permit Issued for tits application wig be N compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME itinalqb A A 1 i.Y/€ IucENSE#(`t L</ I SIGNATURE
MP❑ gia. CORRPOO/RATION❑4 IPARTNERSHIPE# LLCQ#I•
COMPANY IM( (•-•14,10 PV—� 'ADDRESSI 2) f/la�/�/? liftQ
crrY I /1 e 5 (STATE VOA ZIP I 4 264/ I m J ' / Y/0 9't z I
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