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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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* CITY \\/a r M o v MA DATE ) z 7! i 2 PERMIT# P Ar-e 79
JOBSITE ADDRESS I 5 rrl , sr ic• Wffr\A-OWNER'S NAME T� CUY'io
OWNER ADDRESS TEL F X
TYPE OR OCCUPANCY TYPE COMMERCIAL El E UCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: E RENOVATION: ❑ REPLACEMENT:DI PLANS SUBMITTED: YES❑ NO❑
FIXTURES T FLOOR-- BSM 1 2 3 4 5 6 7 8 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
LAVATORY
f ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK 4_S4—f
TOILET 4I URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING 11;
OTHER ,i J
INSURANCE COVERAGE:
I have a current liability insurance policy or its substa tial equivalent which meets the requirements of MGL Ch.142. YES NO ❑
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY 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
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 co
.i nnce with all Pertir nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# SI TURE
MP ❑ JP(( CORPORATION El# PARTNERSHIP❑.# LLC 2#
COMPANY NAME Ce.s�Oo Isr.b��� ��e�I ��} ADDRESS 15 5„✓�
CITY Q v c STATE ,"/ ZIP O 2-/G GI TEL 6 ' 7- 2 0 r:fa '2
FAX CELL EMAIL i t C� - Yl�,,cC. C G M
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