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MASSAC,1JHUSE�TnTS UNIFORM( APPLJCATION FOR A PERMIT TO PERFORM PLUMBING WORK
jCITY 5r' Iar�U''I/l\jf-"4 MA DATE (I /50f�'3 P R#/JCnz3 +
a ✓"�7
JOBSITE ADDRESS/077 /4/� 5 /Zed, ' CJ OWNERS NAME/Yf9,n y, i� sa
POWNER ADDRESS i TEL 7 - 61 -0 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 57 EDUCATIONAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:[A, PLANS SUBMITTED: YES 0 N9t.el
FIXTURES 1 FLOOR-' BSM 1 2 3 4 5 6 7 e 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
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR) _
KITCHEN SINK p
LAVATORY ! F tT. V_
ROOF DRAIN
SHOWER STALLN d c7 202�
SERVICE/MOP SINK 1 7I
,
TOILET T
URINAL 1 uii-olrvw't'nl_
WASHING MACHINE CONNECTION t, —- _
WATER HEATER ALL TYPES ,
WATER PIPING _
OTHER _
p 17,ZA. nevi Catl'ko c Ta r / _ -
0 f/C D/2 q d r:..'/-7 1 - 1
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY INSURANCE POUCY ❑ OTHER TYPE OF INDEMNITY 0 BOND 0
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.
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
1-1I 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.
PLUMBER'S NAME 1 t\d14 e L.- `r� LICENSE#/���/ ¢ `
SIGNATURE
MP 0 JP fti
n CORPORATION 0#p COP"" PARTNERSHIP❑.# �LLC 0#
COMPANY AME 0\v(-� I i 1(`' .--- 1- ADDRESS �7 F'r`'l'f�I r1 ' ` ve
CITY l e4!"1N\ S STATEM4 ZIP ozz,e/ TEL 77,/Vo 9/zz
FAX CELL EMAIL 31-1(ycj el-- P1 C..J3 r a CXJ®,,,444 // (ndi
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