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MASSACHUSETTS UNIFORM APPLICATION FOR ERM TO PERFORM PLUMBING WORK
— CITY t . C{ r�O(�✓�'�/ MA DATE - PERMIT# LOP-2 -2-5 7
JOBSITE ADDRESS 9 g/.�5 ,r! Y/),r i-/v/ OWNER'S NAME e PPr/Q y 7
pOWNER ADDRESS (0 7 TEL327'i?? FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL z_ig 6.4,"5>
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:4f PLANS SUBMITTED:YES ar NO 0
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 -r
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM _
DISHWASHER /
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR 1 AREA DRAIN
INTERCEPTOR(INTERIOR) `� n
KITCHEN SINK / _
LAVATORY _ •
ROOF DRAIN 1 .,i n)2 20;1
SHOWER STALL r I"IM\
SERVICE/MOP SINK _ „o �FNT
TOILET t BU L)nvO W
URINAL ��
. j 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. YESk NO 0
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
f Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER❑ AGENT❑
SIGNATURE OF OWNER OR AGENT
..l 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 jr this a p(cation will be in compliance with all Pertinent provision of the
Massachusetts State Pl/utmbi Code and Chapter
14a pipe General Laws.' l/S/- / \ _
PLUMBERS NAME �"1 ( �1P 1- 4 "i-' *� �� R` A `J��
LICENSE(� SIGNATURE
MP 0 JP - CORPORATION 0# (()\• PARTNERSHIP Q# LLC 0#
COMP Y NAME "' '" c t"`� p 0 1 ADDRESS 7 r—rci LJ 14 b 11(J'Q
CITY 6l iN A\ S STATE`I V"\. ZIP !') 2(0 U / TEL
FAX CELL EMAIL
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