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I MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK ;
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=�j_ CITY MA DATE 7////2-0/6 PERMIT# /✓ /1 j!�—
JOBSITE ADDRESS 7? Nee iZQ• OWNER'S NAME J 9N i6/ cs
OWNER ADDRESS ..-. TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL gr-
PRINT CLEARLY NEW:[RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO r�
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FIXTURES 1 FLOOR—, BSM 1 2 3 I 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE _--MUM___---_
DEDICATED SPECIAL WASTE SYSTEM ------- ------
DEDICATED GAS/OIL/SAND SYSTEM _____---_�DEDICATED GRASE SYSTEMEM1111111.111
■■■DEDICATED GRAY WATER SYSTEM
D SDHICATED WASHERATER RECYCLE SYSTEM 111
---I
DRINKING FOUNTAIN 1
FOOD DISPOSER 111 1
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK III
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
11
OTHER
I
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO E
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY V OTHER TYPE OF INDEMNITY ❑ BOND ❑
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 regarding this applic ' e and curate t est of my knowle ge
and that all plumbing work and installations performed under the permit issued for this application will in omp' n 'th rtine t visio of
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME D4-vi�4. • LICENSE# 0.3 77 SIGNATURE
MP 1 JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME KOSS l ADDRESS ,..36 ii I6 7^J �V _
CITY Wes r yof 0 ✓ STATED • ZIP 0 Z-6 73 TEL 3Y' 7 70,/' ff/
FAX CELL -367- `/V 2 EMAIL / ✓l� /TVA/0116. CO$7
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