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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
fi S" CITY MA DATE `2�1 " PERMIT#rural '-OC 3 i/ 7
JOBSiTE ADDRESS 7 6�1 s v CI OWNER'S NAME ill' e,
P OWNER ADDRESS 6 6 f4c k it1 16- e/Its I IL TEL di'S' 7 j J-2/2 / FAX
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TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑a RESIDENTIAL[6,
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:EV PLANS SUBMITTED: YES❑ NO❑
FIXTURES Z 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 I AREA DRAIN L-t U .L I ti
INTERCEPTOR(INTERIOR) _
KITCHEN SINK ^,
LAVATORY _
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
yr.I Ire WATER HEATER ALL TYPES
- S c J 'I°Piy WATER PIPING
OTHER
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INSURANCE COVERAGE: /
have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES C9' NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY L_7 OTHER TYPE OF INDEMNITY 0 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 and acc to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in, nce ' �I Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
NAME '
PLUMBERS
4 / G v /J C h d s LICENSE# To/ ✓ SIGNATURE
MP/K, JP❑ CORPORATION lialt Pt 6, PARTNERSHIP❑# LLC❑#
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COMPANY NAME L-NO c' LotV , ADDRESS g Fr';!/te,ec.0 )C.)e'__
CITY c V "v V' iTh STATE'6^'tfq ZIP 0 A,Cv 6r• TEL 37,6 //CV-•Z-/
FAX_, u b 7 c3 y .5"7 k CELL 5-Ct I%D p /5a4. EMAIL 57, 6 4 .14.4cA, S ivy
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