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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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��, ' CITY �7`r('Wl(?U�"� 3'� PERMIT# /�L/�/�-AO-00670
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� � JOBSITE ADDRESS NI( Oratvexze DR, OWNER'S NAME_,11-SS;.CS L,i-4 4 L LC,
POWNER ADDRESS I TE( p) 753 ?S q4r FAX 7
TYPE OR OCCUPANCY TYPE COMMERCIAL 1 I EDUCATIONAL ❑ RESIDENTIAL4
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CLEARLY NEW: RENOVATION:I REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOD
FIXTURES 7 FLOOR— BSM 1 2 J 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 7
-1C71-r"-,f_ - r' - 1 - -
CROSS CONNECTION DEVICE r , u
DEDICATED SPECIAL WASTE SYSTEM r j
DEDICATED GAS/OIUSAND SYSTEM J 11
DEDICATED GREASE SYSTEM _
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DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM r -II— 1' lr -?I- 1 _ -ll i
DISHWASHER r
DRINKING FOUNTAIN i
FOOD DISPOSER
_FLOOR/AREA DRAIN 11
INTERCEPTOR(INTERIOR) L
KITCHEN SINK L [ ]L
LAVATORY r
ROOF DRAIN
SHOWER STALL r
SERVICE/MOP SINK L
TOILET —'
URINAL
WASHING MACHINE CONNECTION l 1 --1'—
WATER HEATER ALL TYPES
WATER PIPING 1 ' .0 it r
OTHER ( L.. etc 1n ll t ii l ,
_ , ( ii
—11 ii
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Ig NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY N. OTHER TYPE OF INDEMNITY BOND I
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 n AGENT
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 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 _Ifi 5 .{.1 ` �� _
�-.ap �� LICENSE# ►�RQ SIGNATURE
MP IA, JP ID CORPORATION#a366C PARTNERSHIPD# LLCU#
COMPANY NAME DGjn 0-1( fsc. ADDRESS I a s Tex s `mil
CITY A-' ftwnf STATE /,A ZIP 0 I U (00 1 TE cj/3>5 - 6wo
FAX S17-DOYa, CELL EMAIL Ia5Oboh °£OCo Ailed Ott .Cpn1
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