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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
11. t * cry - _. u -i t7 I MA DATE . PEW** P/, -co S. 9 S
: . JOBSITE ADDRESS L 3 avilf23 Dr , I OWNER'S NAME 5(.,,-;nn_ I,�/r,,-, ., 1
.i. ER ADDRESS 1 TEL�'SO5t )344-4�LIFAX
0 E OR FANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL 111
Ul PRINT
LEARLY :0 RENOVATION:Q REPLACEMENT:(d PLANS SUBMITTED: YES D NO❑
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FIXTURE&1- FLOOR-. BSM 1 2 3 5 6 7 9 10 11 12 13 14—
BATHTUB 1._~
CROSS CONNECTION DEVICE +aft. my ig
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOIUSAN D SYSTEM - MN MI L M _ M il N M:;
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM Lpir
DISHWASHER
DRINKING FOUNTAIN ' iiiiiiiiii
FOOD DISPOSER -1.116111.181. ow(m no gm NM allill111111111
I 1 DRAIN
INTERCEPTOR(INTERIOR)---
IN
KITCHEN SINK
LAVATORY
ROOF DRAIN E IIII.IIINS.SHOWER STALL „ ,. .
SERVICE I MOP SINK MOM PM MUM NOMN 1MI
TOILET M—MaillialliaN"MIN MIUM1.1111M-
URINAL 1
WASHING MACHINE CONNECTION ilin —
WA I ER HEATER ALL.TYPES ( _ - .
WATER PIPING
OTHER
NM 111111111111111111. 1 Eli mint 1111 11111111111111 am _ _ _
.- - .... __
MIR _
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES V NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY d OTHER TYPE OF INDEMNITY [J BOND Li
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
SIGNATURE OF OWNER OR AGENT_
I hereby certify that all of the details and information i have submitted or entered rung this application are true and accurate to the of my knowledge
and that all plumbing watt and Installations performed under the permit issued for this approbation will be in c" nce with t provision of the
Massachusetts State Plumbing Cale and Chapter 142 of the General Laws.
PLUMBER'S NAME •r . PA. ' '.G !LICENSE# b a-o ,— - SIGNATURE
MP RI JP® CORPORATION Yi#67s C, 1PARTNERSHIP Dit 9 LLC I
COMPANY NAME ; 41Wrde. PA_p, L-L•_I ADDRESS =i1_ i? acJ .C' }J . f
CITY o.r-rrav4 _ 1 1�/�/ STATE ()IA IZIP 612.6773 I 1EL[ C6 & `_4
FAX 60t?71a-t 1+t CELL EMAIL
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/71/9P ,BAR e &/
F- .5Z,. MASSACHU SETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
== CITY !Town of , \7A V m D u i bj_ t MA DATE? A PERMIT#/3DP 0 00 5 '
JOBSffEADDRESS! 3 Pll y 1.) 5 P_ - OWWNER'S NAME 1 3i
OWNER ADDRESS j i'1E1 5o1j "Y)4 - /4 F�(.jL-FFAXI_T_
TYPE OR OCCUPANCY TYPE COMMERCIAL Li Fn1 ICAT10NAL 1 I RESIDENTIAL LW
PRINT
CLEARLY NEVV:ij RENOVATION:Li REPLACEMENT:i I PLANS SUBMI I i b): YES[J NOD
APPLIANCES-1 FLOORS-+ BSM 1 2 3 4 5 6 Zia 8 9 10 11 12 13 nil
BOILER -
BOOSTER Wt_
CONVERSION BURNER iliii Jim illiN _ _ allr 111111railir_ C�
COOK STOVE • _ — . _ — _ . li
,.-. - .M
DIRECT.VENNT HEATER MI I � —.— ma a�7�•— I .
DRYER a A.,— — —WU Nor N.an o f
FIREPLACE __ _ MU MB j• i _ .jiiiiiitrilk anir jilwiff
FRYOLATOR 1111101 Urn I r oar
FURNACE 111111111111E.1.1111.11111110111111.1111111.M.1.1“.11111
GRIT I F
INFRARED HEA I ER _ a j_W am — ow ow amY�
LABORATORY COCKS i , ,rs t:,?L'. •'�3... ` L�; ,...: +..}ai
MAKEUP MR UNIT A `" gill ' is.:4_441
Hai. wit _ i..
POOL HEATER . I _ I. L. .L i ...A.. ...L .... .:. 4.1L al
ROOM I SPACE HEATER i _ _ - � =I .Ma +tom :dal A WI Mg
ROOF TOP UNIT - r t
TEST 1 =If 1111111111111 at.M NW—pm M malt
UNIT HEATER _. . __ Mt a
UNVEN TED ROOM HEM ER an a mg ow
WATER EATER it —. W I R I owII.
OTHER
- v_ _ �- !it am _gm ass
-11111E1111111111111 Mill a— 1111111111111 111111i M a[
INSURANCE COVERAGE
I have a current liability insurance policy or its sub antial equivalent which meets the requirements of MGL Ch.142 YES EiriNO U
I F YOU CHECKED YES,PLEASE INDICATE THE TYPE OF CO GE BY CHECKING THE APPROPRIATE BOX RFLOW
UABIU Y INSURANCE POLICY OTHER TYPE INDEMNITY 9 BOND Li
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 d AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and informafion I have submitted or entered regarding this appficafion are true and accurate to e best of my knowledge
and that all plumbing work and instailafions performed under the permt a eueci for this applicafion wit be in compliance } ant provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER GASFfTTER NAME igerV;r, c- jF:JP A UCENSE lj O - SIGNATURE
MP a MGF Li JP Li JGF Li LPGI Li CORPORAT10N #[a 8(,F G PARTNERSHIP Diti 1 LLC 7 —I
COMPANY NAME Youn-m' r;a�. Plum 4 j ADDRESS I (I �nj, J Pe - 1
CffY [ 0 ,rrnnc.-4- _J STATE!ill_I ` 673 JTEL p_s)_ 455.6 •
FAY 1:)7,10--4;7851 CI1L EMAIL