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� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY //'r.e_:/�i, c, r-�� MA DATE _/,�Z—/Z �/�f , PERMIT#���`��6 �fC'/
JOBSITE ADDRESS �? 7 CCJ/N�'�/�/' /P� OWNER'S NAME LU�?�Z�nN
POWNER ADDRESS TEL FAX
I TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL,.�
I PRINT
i CLEARLY NEW:❑ RENOVATION:� REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
iFIXTURES 7 FLOOR� BSM 1 2 3 4 5 6 7 8 9 10 11 12 73 14
� BATHTUB
I'i � CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
� DEDICATED GASIOIL/SAND SYSTEM
� DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
y� DEDICATED WATER RECYCLE SYSTEM
� DISHWASHER
� DRINKING FOUNTAW � 0
FOOD DISPOSER . a"' � [
N FLOOR/AREAD I � �l � }�
� INTERCEPTOR IN ER R t
KITCHEN SINK � CSF L b � E
LAVATORY ` _..-.-�,.�,,��.� `t �
� ROOF DR41N i,i-.�'C D<" _ '
� SHOWER STALL _ _
SERVICE/MOP SINK
� TOILET
� URINAL
WASHING MACHINE CONNECTION
� WATER HEATER ALL TYPES
�,.` WATER PIPING
OTHER
C �
INSURANCE COVERAGE: ��
I have a current liabilitv insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES p� NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE NPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSUR4NCE POLICY t� 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 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 thedetails and information I have submitted or entered regarding this application are true anccd��annccurate to the besi of my knowledge
and that all plumbing work and installations pertormed untler the permit issued for this application will be i p`�ertinent provision of the
Massachuselts State Plumbing Code and Chapter 142 of the General Laws. .
PLUMBER'S NAME LICENSE#���9 SIGNATURE
MP� JP❑ CORPORATION�# PARTNERSHIP�# LLC 0#
COMPANY NAME ��A �6 / a✓(.BKy ADDRESS �G� /S��
CITY��N c.� t �/'� STATE� ZIP ()2 6t/C TEL �0��3�7(n,��
fAX CELL EMAIL
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