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MASSACHUSETTS UNIFORM APPLICATION FORA ERMIT TO PERFORM PLUMBING WORK
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s_ CITY `�' f ti IA DATE 6 z 2/1 PERMIT#R L OP- Z4-1- 5 1-
JOBSITE ADDRESS 2 0 NER'S NAME M ItAl Al 0(1 CH.
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY COMMERCIAL 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 1
DEDICATED GRAY WATER SYSTEM _
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY E C r- V E. D
ROOF DRAIN _._.__._.. .._.._
SHOWER STALL ,¢
SERVICE/MOP SINK J� ill y �11_0 L
I TOILET / _ +
URINAL aF PAR Tn,FNT
. , WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES ) •-• ' -
WATER PIPINp c
OTHER puye.
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYP F COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY 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
ki.I 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 comer nce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME 5c._,_41 LICENSE# )6.--
!j G{ SIGNATURE
MP JP El ❑# PARTNERSHIP✓ ❑.# LLC❑#
COMPANY NA 'E 12-1- P L ADDRESS Z-�/ 4"v 7-14 Q�cl (16--b
CITY ) r l it WO 0 2STATE it4rt ZIP TEL
FAX CELLYg3CP 3 f T 4 EMAI // .()/
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES