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MA,SSACHUSETTS UNIFORM APPLICATION FOR PER IT TO PERFORM PLUMBING WORK
Tl7^„ CITY f/V- �C
= 1 r cJ MA DATE Z PERMIT# EL OP"2-'1-10
JOBSITE ADDRESS,
I I IC,Q C .it" Al q 11 5/ OWNERS NAME CpP �q,/- s
OWNER ADDS` l I TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL I' EDUCATIONAL ❑ RESIDENTIAL E
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED:YES 0 NO RI
FIXTURES 1 FLOOR-. 9SM 1 2 3 4 5 6 7 8 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 I AREA DRAIN —
INTERCEPTOR(INTERIOR)
KITCHEN SINK -
LAVATORY 2_ �3 _
ROOF DRAIN J
SHOWER STALL 0
SERVICE/MOP SINK
TOILET �a....� 1
URINAL FFR 1"2BE1'
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES® NO❑
t
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY s OTHER TYPE OF INDEMNITY ❑ BOND 0
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 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
LI 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.,e j s/
PLUMBER'S NAME Pill!CL'�t`' - I c D r 2 e LICENSEE# ` SIGNATURE
MP❑ JP❑ CORPORATION/ 0# r PARTNERSHIP❑.# ) L.LC❑#
COMPANY NAME t'\�I?/'I G P H ,^^ ADDRESS 7-
7 ran LAG el G1 1G
CITY , Gi �111 S STATE M4 ZIP 0 1 (9 0/ TEL 77/ /& %l zz
FAX CELL EMAILn' 1.1C)t -•nx,LTV
— C/0 34aD q20 ci(g(al(D
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