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-4- .a., MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFIWFWMEONG
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_, CITY Ya f ✓v10 L4 ! MA .DATE[ 1 PERMIT# 8 LoP-Z r- 1 sir
JOBS)TE ADDRESS I •?7 ,n el in s•71-0?o i,fe *2$)0 OWNER'S NAME j-)Ot 'R 05 Iv\,e1.\.N. I
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N)i TYPE OR OCCUPANCY TYPE COMMERCIAL Ege EDUCATIONAL ❑ RESIDENTIAL 0
C CLEARLY NEW:0 RENOVATION:5,r REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOD
J FIXTURES Z FLOOR-0 BSM 1 2 3 4 5 6 7 8 8 10 11 12 13 14
*-• DEDICATED SPECIAL WASTE SYSTEM
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s--, DEDICATED WATER RECYCLE SYSTEM MIN MIMI AIM:11111,11.11 JIM AIM pm immi , 1
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INTERCEPTOR NTERIOR
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LAVATORY •
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SERVICE • M M`M:Oil;_._
URINAL
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WATER HEATER ALL TYPES a ii...iiiiii11111111:111111111111M
WATER PIPING
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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 TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY a" 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
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 an 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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. , i l
PLUMBER'S NAME 'i44< 'JYJ-�r4 ,e7-i - LICENSE# &SAW) SIGMA ,
MP Er JP❑ CORPORATION 1 3, . `7 IPARTNERSHIPD#[ 1 LLC❑#
COMPANY NAME ,4///6/475 / j :1-.7 C ADDRESS //( z ' ,5
CITY /ice. a Pe711 , MI I STATE ZIP 7 i;'2' :?
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