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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY las-"r^ `
0 MA DATE - l 2.1) �) PERMIT#A-02.-/1—®UZ'Jy
JOBSITE ADDRESS `tS -C OWNER'S NAME`nonr. c akreN
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL tom'
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:, / PLANS SUBMITTED: YES❑ NO lEtr-
FIXTURES T FLOOR-P. BSM 1 2 3 4 1 5 & 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM _._.____....._____. __
DEDICATED GAS/OILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM _DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR 1 AREA DRAIN
INTERCEPTOR(INTERIOR) !Ur
KITCHEN SINK
LAVATORY _ _ -_—
ROOF DRAIN
SHOWER STALL
SERVICEI MOP SINK -----
TOILET
URINAL _ — -
WASHING MACHINE CONNECTION _
WATER HEATER ALL TYPES t
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 ViNO ❑
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 1 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 c pliance with all Pertinent provisior�of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME lira[ dazShop. LICENSE# I5lO1 IJ / SIGNATURE
MP M/ JP❑ , M CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME tC$ 1 e nil ADDRESS c 171(e) cx.Lc , .30
CITY 5C1 dlA3lrlin STATE M J • ZIP Or,F,)t 03 TEL `."7M 95'5(0
' FAX CELL EMAIL YV)O I19 i�lI C h-e �ci e nCC(f(C•CO fl`1
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