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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
I.--`ail-; 1CureNO,-I}h MA DATE ! f � , , PERMIT#//�/���Y L(c
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CO� CITY ],[,, ���(( �/-
JOBSITE ADDRESS 1 ` {"►� i✓"�avf FU s' WNEE S NAME ��� \ v ►rr
P CI61 Corr ' \Jcrrri, Po
OWNER ADDRE55 \` , Z `� TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL E EDUCATIONAL ❑ RESIDENTIAL(�--"------
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMI I I ED: YES❑ NO❑
FIXTURES 1 FLOOR-# BSM 1 2 3 4 5 6 7 B 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/AREA DRAIN _
INTERCEPTOR(INTERIOR)
KITCHEN SINK
I LAVATORY _
s ROOF DRAIN I
SHOWER STALL
I SERVICE I MOP SINK
TOILET I _
URINAL _
. { WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO ❑
I IF YOU CHECKED YES, PLEASE INDICATE THE TYP COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
I. Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
rl I hereby certify that all of the details and information I have submitted or entered regarding this application are 1 ,and ac to best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co/:fiance ' Went provision of the
Massachusetts State Plumb' g Code and Chapter 142 of the General Laws. ,
PLUMBER'S NAME I� cl✓� �J�� '�' LICENSE# /526b
/ SIGNATURE
MP IV JP❑ CORPORATION ❑# PARTNERSHIP❑.# LLC 7 'Z
COMPANY NAME Ct(.K, 1--\V\PnCtCJs-c ' P.3/ ADDRESS f 4 CAc incl.5-- L ✓`
CITY CAS .obi—e STATE I1 " t ZIP D 7
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FAX CELL g—3/ 7- /-7 L`01 EMAIL 7 til,eq0Cf LN 0 CP*Crt,S I. iv t
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