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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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' MA DATE 1�� 4 q PERMIT# B
JOBSITE ADDRESS PIMN,Y�i,-t_.A\�7-�,�Jd
OWNERS NAME UW ft"S .0G-�4
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P OWNER ADDRESS 6-73 �'W/ 2* W yafor'`B It '77 q-AI2.LID35 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO
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
DRINKING FOUNTAIN -
FOOD DISPOSER
FLOOR/AREA DRAIN 1
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK R e x
TOILET a -
URINAL i
WASHING MACHINE CONNECTION - -
WATER HEATER ALL TYPES _ _
WATER PIPING -- }
OTHER
jDULC ING u_ - MEN-
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES, NO 0
IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 1
LIABIUTY 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
` Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER❑ AGENT❑
Z SIGNATURE OF OWNER OR AGENT
Li1 I hereby certify that all of the details and information I have submitted or entered regarding this application am true and accurate tot t of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in com . 'th I Pe revision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# 9?,°-' . CJ SIGMA RE
MPIZr JP❑ CORPORATION❑# PARTNERSHIP Q# LLC❑#
COMPANY NAME FD(rPSJ 1 61 ADDRESS LD 0 a t 2
CITY S 06-0lAiti C STATE Mt- ZIP D 2-5:-.Z0-• ///�,,,,������.���`����"""TEL
FAX CELL gg�i.)Zd y� EMAIL 4 0 cir� iti d it4(223, 49-77,-)
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