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MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM PLUMBING WORK
�er'�9 CITY MA DATE PERMIT*1#4/1L9- /87
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JOBSITE ADDRESS U/y Qi°f d 70 OWNER'S NAME • k* _D 131'•
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL\R
PRINT
CI FA RLY NEW:0 RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED:YES 0 NO❑
FIXTURES 7 FLOOR-, BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14 J
BATHTUB
CROSS CONNECTION DEVICE -I_
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OILISAND SYSTEM
DEDICATED GREASE SYSTEM - _
DEDICATED GRAY WATER SYSTEM
1 pi
DEDICATED WATER RECYCLE SYSTEM —~
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK L
j LAVATORY • _
• ROOF DRAIN Ittl_ 4.'
SHOWER STALLC_V
SERVICE/MOPSINK
TOILET
URINAL
WASHING MACHINE CONNECTION r
WATER HEATER ALL TYPES
WATER PIPING
OTHER
Ill .-
j INSURANCE COVERAGE: �r 1
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES BO NO❑
IF YOU CHECKED YES,PI FCSE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW /�
UABILT(Y INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
j Massachusetts General Laws,and that my signature on this permit application waives this requirement.
T CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
'A-I 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 priance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME UCENSE#/O/2/ . SIGNATURE
MP Ni JP 0 CORPORATION❑# PARTNERSHIP 04 A LLC 0#
COMPANY NAME/I h/l(C.) ADDRESS (0 7 t"1 e�/ )4 Lie
CITY 1,"'l G vt A r i STATE'4- ZIP CO260( TEL S V -77 I---lam -a�
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FAX CELL EMAIL Vyl co Q- ��µ l(GS . /(1•t
ROUGH PLUMBING INSPECTION NOTES BELOW FOB. OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT It
PLAN REVIEW NOTES _