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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
it"WA 'Q�' ,,,G / PERMIT# P l7P/ II�1O
W i , CITY VOLPO V P rT _. I MA DATE 1D-LI 49
JOBSITE ADDRESS `I�..y (,(I.�.1[,,�,t�.�__�___�__� OWNER'S NAME �} I
POWNER ADDRESS .54.rl C _ TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL u RESIDENTIAL E'
PRINT
CLEARLY NEW:❑ RENOVATION:Er REPLACEMENT:0 PLANS SUBMITTED: YES D NOD
FIXTURES 7 FLOOR--4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB ) L.. ....1i.__r__Q__..,,,_.I_. _..__1:.___, .I�. ..�1I.... .,.II._..�_.__.1I.,�,_.,. w�- _.(I._._ 1L. ,.,.�_ I.....,...I
CROSS CONNECTION DEVICE I-- --1, =,=l' !< I i��a!1.. --Y--J(- 4 L---� I._ __1 7� 1 _,._,.JL_,
DEDICATED SPECIAL WASTE SYSTEM ; �nf.____� _JL_y.L,. JL .:_�.�_� _._r f- L.�, _I _..r. L--J
DEDICATED GAS/OIL/SAND SYSTEM .„__._,f,m._,Ji=„n. JET,11 11 _A =1 .-_IL_ ll.-_,- ' D=-- i
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DEDICATED GREASE SYSTEM I = ,,.._._-L z_R, _, ,L..,_ ii__ _. I_____.1I . .I____ 11 __.J
DEDICATED GRAY WATER SYSTEM I,__IL .,1I__9 _ 11�... I�, ,.iL I1,-r, _ --...J.
DEDICATED WATER RECYCLE SYSTEM J,,_J; AL _, J! _ L __JL
DISHWASHER I..,. _1 a_ __ (I..._._�! � 1L,,..—).1�.�._ '--.:.:1�-¢_�_.,.II----. `1- -
DRINKING FOUNTAIN L � l,__�a_II 'L,: ?. ��- cI�_s, I__ ,. L_�_y.: Im.,,...IL .
FOOD DISPOSER I�.,.,,. I 1' -�I_ 11 3, ., k ,_ 1___IL__:I._,__. ( ____... .
FLOOR/AREA DRAIN 1 ^ __ ,1..-._ ._ ii ____L__ ..11, `'I -� .1I ..L_
INTERCEPTOR(INTERIOR) 1� ,.,.�1. 1 -nl!,,..�1L..._ i ,.,_.II P,e.. ,. II„o.. I-. 1[7:71 ----1 -LI
KITCHEN SINK , ._ I.-. ..---=-ti��.e.j1- ILL.AL v..°L....-1__,..,J___.4L r_ l__ :IL...r ...,..9(__..__1
LAVATORY I II;tt._Al 11 __ I __ 1 1I 9L.w II..,�.___......_ JLm ___J
ROOF DRAIN L ' I I; IL .__1i_,.�.._.1�._ I s_! .�_ ([___J
SHOWER STALL I 1. ._v 1 1 ,_fI ,__.1i -17 l _ iI_,._ (I .__I,
SERVICE/MOP SINK I _IL i : a11 _, II-_, ,1L__ -I( I1.,. il-, L.._JL _..11._____I
TOILET I: . j .?J_ >I ! __. (' §i....,..: 1I___, . :1_, ___.'i, I' _. IL I
URINAL I y„ I{ li,esl. 1 ,L J'I 41 L 4..__ 1I iL_...'sl I�. if
WASHING MACHINE CONNECTION a' =x:__.11_zn,.z.1. _ 1 -'1._ i .._r 3I_..- ai_=- �.1L�.v.1 ._._�.sl-�.!
WATER HEATER ALL TYPES 1 _a_11t_ _..'L. I__R i I .._C _:I._,_., II il.�..,o.,,l
WATER PIPING I _il 1 11 JI_ .,,_1L.�_ J y 1 L �_(i�_ .L.:� 11 L
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•THER �_. _ 1 I-� _ t L . as _ 1
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' ! — 1 I• L� d I d i� _ 1_ s._,.'I_�_ I_ d I .J,,_._....__s.i'_._____ ...�,___ L.._f._ L__J
sex—.�..._.__...���.._..�—.�..._..._.._:� ..��.� . �_..� .�..�,..�.,�_„ a.�.,.._��... _ r�. ._ ') `I (�
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 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER U AGENT Li
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and acc rate to the of my know!ed e
and that all plumbing work and installations performed under the permit issued for this application will be in corn ' c Pe . nt ovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �-
,D .�///�
PLUMBER'S NAME /fhQ.tL, 1..._ f.tiirQ,_.__. LICENSE# PATen. SIGNATURE
MPEr JPQ CORPORATION,. # - PARTNERSHIP rLLCL# _ LL I
COMPANY NAME/ Pi-re,/4 i 1i t /-' I ADDRESS L/(v)rcr4cc. J..,/1 i
l _CITY eji. V/r�- -1,;_STATE )Q y ZIP 6 4,263,2__-. _J TEL ) "-7 Q 0 oZC0 z( 1
/ I
FAX G I7T�O� y(O . EMAIL f
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
j Y1 A-0 �644�/77//e Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: S PERMIT#
PLAN REVIEW NOTES
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