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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
I-1 CITY. kr'U r vvt t10(1 _ —_ ____ MA.DATE 0 51t0/i i I PERMIT#A-OH `G°&'��
JOBSITE ADDRESS 5 PDi ar 1, Fri_ OWNER'S NAME G 41yn 4 1 '
P _.OWNER ADDRESS 5 131..ad Q({ TEL !FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL U RESIDENTIAL C
PRINT
CLEARLY NEW:[I RENOVATION:® REPLACEMENT:0 PLANS SUBMITTED: YES® NO®
FIXTURES 7. FLOOR-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 11 t..P..s.IL _ILL__I _ I , Jl 1. . . II . _ L. Jl
CROSS CONNECTION DEVICE L_.,_,.111 __JI. 1—JLJ Il JI,._, J1, il ._4-I____,'I __.._ �i._.T-s11 _II
DEDICATED SPECIAL WASTE SYSTEM L _ 1 I _A_. 1 _ _I _._ L_.._.IL I__.__ 1__. JL 1_�. 1_____ $1 ._i
DEDICATED GAS/OIUSAND SYSTEM L__ IL J. ,_ .. L_._.__1L_.___II_.__._.JL_ JLm J . _3L _JL.__._II .___[L__.eJ___,_-_I
DEDICATED GREASE SYSTEM Ls_ i t — IL_ IL._J <<°.I ' , L._ I _JI I 7—_J
DEDICATED GRAY WATER SYSTEM I .�?I__ ,,- JL I r .--1 1.-__11_____ lA_
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,._„_DEDICATED WATER RECYCLE SYSTEM _ai J
II_ - 1_ __IL _. i ...„ rL_ I _IL_ _ Le.„.IL ._...: _, _II _
DISHWASHER L li .`'1-iL L�__iL.__IL � 1_.._ ,. L 1._ AI _ L1_. ��L ____ ,_
DRINKING FOUNTAIN I -. I____II _.)JL _J_.__Jt_._J . _ JL_IL L_JL.-. J1_L _-
FOOD DISPOSER I .-._ I1. �_1t 11_. _II—_ . _I [-I.1_..__„J _ �..IL , I _____11, F IL _It
FLOOR/AREA DRAIN —�Ly __. _6L._. .1i l 11 L 'L_L�. _L. JL _ iL —1
INTERCEPTOR INTERIOR) I J! Jl_ 9, �� la 9 I ----1
KITCHEN SINK =—�d I_ ! El Lm,..� -4= 1 ..___I ? 1
LAVATORY UI >. tll I - I.T 1. . L .1. II—IL IL- I �_ ___:
ROOF DRAIN 1 I_ _ - __ I it SI L- _
SHOWER STALL 1 91s-. ''. 1 .i_.._ [=J1. _ 1'._..1 ! i _�.JIL_ ! _
SERVICE/MOP SINK _ _ _IL IL_ . `' =_..IL...= II -Lim —,I _I! .iL IL_ _II. IL._ I
TOILET , - 1 . II __II_ �L I la _ l,. _IL _'_ 11.11111111 Mil
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URINAL I ,__ L_._1 ..�_)I_ - . # __3l _i 4 __.-'._. L--- f' _ __
WASHING MACHINE CONNECTION I- }L ' . . -1'zr -..1. -�J I_.,,, _ �(r_ ;(.._ __ifs s fl.._ 1 �I_ -__I
WATER HEATER ALL TYPES I -_ j--- I7—.' f — 1
WATER PIPING L I 1_ 4 _ ._ 'I l I _ t1 a {l. __£ :I - _._, um
OTHER sTT LL �I _ -.. = I _ I.:__ fL _IL_ - I__ _ _
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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 ED -
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW i i'V XrD
LIABILITY INSURANCE POLICY D OTHER TYPE OF INDEMNITY D BOND 0 ; i -
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. /�l
CHECK ONE ONLY: OWNER 1=1 AGENT LI
SIGNATURE OF OWNER OR AGENT .
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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. . //jf.
PLUMBER'S NAME (HrfISA , . Lk,`'‘ ..� _ LICENSE# S S5- I SIGNATURE
MP® JP : CORPORATION LJ# IPARTNERSHIPLJ# . LLC0#
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COMPANY NAME A yt r ( 'I e\ :ADDRESS 7 y. (e ?/ i 0/et441 v�J
CITY STATE . ZIP I TEL SOY-2Qb-U/6.Z I
FAX CELL EMAIL A n SG1 L 1I,' 94) - •✓( ,
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
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