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12x MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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' crrr YOrlmuth MA •DATE .5 2 1 IZ1-1 PERMIT# / 'GI»°�' SU '
JOBSITE ADDRESS 30 COVeV'tCW Dr OWNER'SNAMEf/tIJ Replil COyporCa(I)
p OWNER ADDRESS I I TELJ IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL Cl RESIDENTIAL 1,
PRINT
CLEARLY NEW:0 RENOVATION:Q' REPLACEMENT:0 PLANS SUBMITTED: YES 0 NOD
FDtTURES Z FLOOR-0 BSM NV3 9 10
BATHTUB111111111111111
CROSS CONNECTION DEVICE
DEDii?ät!M
CSTE SYSTEM
DEDC SYSTEMEM SYSTEM
DEDICATED WATER RECYCLE SYSTEM ism am AN:Ng,
DISHWASHER r
DRINKING FOUNTAIN . Rila.M111 RE
FOOD DISPOSER -
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIC�
KITCHEN SINK y
LAVATORY h,
ROOF DRAIN .
SHOWER STALL M 111M—. IN.ME NM IMO AM 11111111.11111 MN AW
SERVICE I MOP SINK �.; r, l 2.
TOILET _R)�:■ :_MR:_ =.
WASHING MACHINE CONNECTION NM; I M. WI IMP'W 1111441111J Mt
WATER HEATER ALL TYPES Irk. , ' i i
WATER PIPING �: W`
OTHER 1111
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immixJ _
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• INSURANCE COVERAGE: •
I have a current ilablllty Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES la-NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILTIY 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 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 perfomned 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. .
PLUMBER'S NAME '4/�;",4 •y i l /-I-k" I LICENSE#�I q,'c`l 1
; SIGNA
417[7.67 '
MP[ JP❑ CORPORATION 3::L 1IPARTNERSHIP❑# . (acD# -
COMPANY NAME 14//iQ3/7/75 P7'if L ADDRESS //i(- -;', ,-5 7
CITY Af,�y4a,err ,+`l�tr. ,STATE �� ZIP ' /, 2 I T I '17e/- k'g� g I
to V r—• t/ t ne..I 1 f I cue" I e.0 D�X- 67(1�QC7(•Corn
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPUCATION SERVES AS THE PERMIT ❑ ❑
FEE:S PERMIT
PLAN REVIEW NOTES
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