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.S MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT 7'O PERFORM PLUMBING WORK
_Jl_ , MA DATE C� PERMiT#��/ 2/�— )6 i7
JOBSITE ADDRESS G) ? 1Ui (,-2a. OWNER'S NAME )
OWNER ADDRESS . ."4.'11..CC- 7 (� TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL ]
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENTL PLANS SUBMITTED: YES 0 NO '
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FIXTURES Z FLOOR aSM 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOIUSAND SYSTEM _
DEDICATED GREASE SYSTEM 1 -
DEDICATED GRAY WATER SYSTEM
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DEDICATED WATER RECYCLE SYSTEM _
DISHWASHER I
` DRINKING FOUNTAIN
I FOOD DISPOSER
FLOOR/AREA DRAIN _ r '
INTERCEPTOR(INTERIOR) i j
KITCHEN SINK I i 1
LAVATORY i I
ROOF DRAIN 1 1 -
SHOWER STALL I -
SERVICE I MOP SINK
' i -
TOILET
URINAL }
WASHING MACHINE CONNECTION i
WATER HEATER ALL TYPES r
WATER PIPING f ' I
OTHER _ f ( 1
INSURANCE COVERAGE: �—
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MG1 Ch,142. YES U NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 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 0 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 pliance with all Pertinent provision of the
Massachusetts State PlumbingCode and Chapter 142 of the General Laws. _
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PLUMBER'S NAME YLA?;1 �.'�ivLr lls�_„mot r `` LICENSE# ri b 3Cj / SIG1493RE
MP;Q JP❑ CORPORATION Q.#`?s-LC C PARTNERSHIP 0# LLC❑#
COMPANY NAME -�(—'c, Pli i:..b;Inn, -,i- 4��� 1,r;._^.•, ADDRESS I S I)/ir�i l.- R7
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CITY <<)tomk lnr, ',_,-1 t,� STATE (7/:i ZIP i rr7c 3 �i TEL
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FAX Z_::c (�4-1..c"1 CELL EMAIL i":rri r.:% �i`?r ,0Ir Air\rinj. .Ylfe:1`
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