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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
•_-• CITY f' k 1O�c MA DATE 11({- I.2S PERMIT#$t,b -Zs-
•
JOBSITE ADDRESS. /7 Ofa 9114.1gsZI OWNER'S NAME A4,dr o. S-1,04e ti S
P OWNER ADDRESS Irk &cQ TEL Gr2O OF3 FAX
• TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL g
PRINT
CLEARLY NEW:❑ RENOVATION:It REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO 0
FIXTURES 1 FLOOR-. BSN 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
ROOF DRAIN
SHOWER STALL RECEIVE
SERVICE I MOP SINK
TOILET 1,
URINAL AI If 4 2025
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES burl urNG ur7`gRTA4tNr
WATER PIPING
OTHER v ----_
INSURANCE COVERAGE: /
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO❑
IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY YLJ 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 t' signature on this permit application waives this requirement
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE e''OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and accural 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 ne vision of the
Massachusetts State Plumbing Code and Chapter 142 9f the General Laws.
PLUMBER'S NAME /closes J aaGt tee LICENSE#2{qD GNATTURE
MP JP 0 CORPORATION❑# PARTNERSHIP 0# LLC pp/#
COMPANY NAME tivlM chcfr ,.O % ,4-,Z. ADDRESS !-' R
CITY .ech'yl`i'(h1a> 7 STATE MO- ZIP O26? TEL 9 q-o�5"/ /2g Z
FAX CELL�?'L-Dr/ PZ EMAIL m�J ee}oct/994 U06'.-a Ze'
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