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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
11 ;1 CITY/TOWN_ (.,C '1 MA DATE -r /n / ' 7 PERMIT#, oP-I r-00/07
JOBSITE ADDRESS(01 fte. • 'J1,Om 417$ OWNER'S NAM Jenfir Lrfrt
OWNER ADDRESS /6 ;M S JUJJ 1L CT TEL ` '(.5S)-yrin FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL'S EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:,E RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES 0 NO❑
FIXTURES 1 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/01USAND 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
ROOF DRAIN
SHOWER STALL _
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
_WATER HEATER ALL TYPES
WATER PIPING
OTHER ILL Flay Pre ve t-t re r 1_
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES IA NO ❑
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 re true d accurate t• •est of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be om i e witi all -_• nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,
PLUMBER'S NAME William Lane, Sr. LICENSE# 8318 SI ATURE t7,1
MP A JP 0 CORPORATION let 3277 PARTNERSHIP❑#_ Lc❑#
COMPANY NAME Superior Plumbing, Inc. ADDRESS 356 University Ave
CITY Westwood STATE MA ZIP 02090 TEL 781-461-1541
FAX 781-461-2971 CELL EMAIL
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