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MASSACHUSETTS UNIFORM APPLJCATION FOR A PE IT OO PERFORM PLUMBING WORK
TV' CITY MA DATE 7 7 PERMIT*51VBC).9I z) 2U�
JOBSITE ADDRESS 2 5—rit' y�eit ti WN R' NANAME >` ,/n
POWNER ADDRESS TEL TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUC 0 RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:-B ;LACEMENT: PLANS SUBMITTED:YES❑ NO 0
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/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) U I V ~ D
KITCHEN SINK
q
LAVATORY to 7 2 �,-
SHOF DRAIN
l ���RRRRNTTTT
SHOWER STALL —
SERVICE I MOP SINK a� —dUILLIIN( H.' EN
M '
TOILET J� ,-
URINAL
WASHING MACHINE CONNECTION _
WATER HEATER ALL TYPES A _
WATER PIPING r
OTHER _
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 THE TYPE ERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POUCY Q' 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
J Massachusetts General Laws,and that my signature on this permit application waives this requirement.
r CHECK ONE ONLY: OWNER❑ AGENT 0
Z SIGNATURE OF OWNER OR AGENT
L I I hereby certify that all of the details and information I have submitted or entered regarding this application are true and curate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complian all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of theGGeneralpLaw�s.
PLUMBER'S NAME
/e t/ �/�`r---A4 74 ��9 LICENS 2.57 , SIGNATURE
MP JP L- ,/�� CORPORATION�g / ❑.## T PARTNE SHIP❑.# LLC❑#
COMPANY NAME
y�y 1X / /7 40/1 1/ 14 7 ADDRESS( —re �p�f--2
CITY `7 '/l„ STATE / S�7 ZIP l;/� J TEL S 0 5 a/
FAX CELL EMAI 0 N
a1/t
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