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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
__- fit CITY j c ar it a', +J TA MA DATE / / 3 c 141 PERMIT#ma 40 X 36D /
JOBSITE ADDRESS )V ,G'i IIey- / Z')'L , OWNER'S NAME C. )ev"i 0 -k4 iZ
POWNER ADDRESS Va(/ Gl/7'yl pe,T 5 ire TEL 5ce 3(7 --f.34.1 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL L1i
PRINT
CLEARLY NEW:❑ RENOVATION:Z REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO El
FIXTURES 1- FLOOR-+ BSIv1 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 I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK '/ _
LAVATORY ✓ -
• ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET V _ _
URINAL - Vti
WASHING MACHINE CONNECTION V
WATER HEATER ALL TYPES ,
WATER PIPING V _ _
OTHER
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INSURANCE COVERAGE: '
1 I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch..142, YES t4O'❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY 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
II 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 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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `qa,rg(2-`
PLUMBER'S NAME LICENSE#/04,r() - SIGNATU
MP ji JP❑ CORPORATION El# PARTNERSHIP❑# LLC # Pit:(-‘ 4.
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COMPANY NAME C r? PL L.' 63 (1*-f l? ADDRESS 5/0 }JC n i,h e D rt v-t 3
CITY/TGL.( 14tLGi G'Z.atf STATE !"!�' ZIP 0a-('ce� -EL •771/ a-oi -7 ?G
FAX CELL 777 ,-`J ) 7 703 EMAIL ( ire j ovrair j0 75 41)c;, `/(, eG
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