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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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v.. CITY t,ck VC4rwQ tL, MA DATE \2 lay PERMIT# 64-OP-1''1— 244
JOBSITE ADDRESS LLD (at c-\ C OWNER'S NAME Key, WI.A.z,
POWNER ADDRESS TEL(%t*) a-4"- 33 S' FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL E;)
PRINT
CLEARLY NEW:0 RENOVATION:[K REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO Tr
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/OIUSAND 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 R ; C '
SERVICE/MOP SINK
TOILET111
URINAL
j WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES BUI` ' -'- M._
WATER PIPING °V
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY 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
Massachusetts General�[ Laws,and that my signature on this permit application waives this requirement.
g e" '' CHECK ONE ONLY: OWNER❑ AGENT❑
SIGNATURE OF OWNER OR AGENT
L11 I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accur to to st0000f my knowledge
and that all plumbing work and Installations performed under the permit issued for this application will be In corppl�nce wit II P 'e p ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `/
PLUMBER'S NAME LICENSE#7634' SI ATURE
MP rn JP 0 '1 ''\\CORPORATION 0# PARTNERSHIP Q# LLC 0#
COMPANY NAME tk ay u.r' % ADDRESS bZ 3D S � L -
CITY e"' ' STATE i'r ZIP n-63 TEL
FAX CELL S`DVJP(,t( ft) EMAIL I'm�5u.( Co aJ�."I-
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT I
FEE: $ PERMIT #
PLAN REVIEW NOTES