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� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK '
��� N�A DNTE• ' " 'l� PERMIT#���15--C'X� iSI.
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JOBSITE ADDRESS �� ��l.`A.«� OWNER'S NHMt/<v.$� �a� SQ
� P OVJNERADDRESS TEL FkX
TYPE OR OCCUPANCY TYPE COMMERCIHL❑ EDUCATIONAL ❑ RESIDENTIAL[7�
PRINT '
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBI�ITTED: YES❑ NO❑ ',
� FIXTURES 7 FLOOR-+ I BSId i I 2 I 3 I 4 5 6 7 B 9 I 10 11 I 12 13 1q �
� BATHTUB � � �
� CROSS CONNECTION DEVICE I I I I I �
� DEDICATED SPECIAL WASTE SYSTEM � � I
DEDICATED GAS/OWSAND SYSTEIv1
� � �
�, DEDICATED GREASE SYSTEM � i
I � DEDICATED GR4Y WATER SYS7EM I I
DEDICATED WATER RECYCLE SYSTEM � I ,
{ � DISHWASHER I I '
DRINKING FOUNTAIN � I I
� FOOD DISP I ,
I � FLOORIAR I
� INTERCEP�OR � � i
KITCHEN 5 K ; i
LAVATORYP ? �j' L � � !
ROOF DRAI�1 '
SHOWERS - , �iLDINCi � TM I
SERVICE/ RiSI '
TOILET � I �,
URINAL ��..
WASHING IJACHINE CONNECTION �
WATER HEATER ALL TYPES
WATER PIPING
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INSURANCE COVERAGE: .
I have a current liabli insurance poliry or its substanUai equivalent which meets the requirements of MGL Ch.1 YE�❑ NO �'-,�—�
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If YOU CHECKm YES,PLEASE INDICATE THETyP E OF COVERAGE BY CHECKMG THE APPROPRIATE BOX BELOW
� WaBILITY INSURANCE POLICY {� OTHERTYPE OF INDEMNITY ❑ BOND ❑ �``��� � � �O!j/
OWNER'S INSURANCE WANER:I am aware that the licensee does not have the insurance covera e r uired b � 142oith___e__�'T _�
9 e9 Y�P�
Massachusetts General Laws,and that my signature on this pertnit applica[ion waives this requirement
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SI6NATURE OF OWNER OR AGENT
I hereby certify fhat a�l of the tletails and infortnation I have submitted or ente2d regarding this application a e a accu2te to the best of my Impv,qedge
and ihat all plumbing work antl installaGons pertormed under the permit issued for this applicallon will be i I' ' aIl Pertineni pmvision of the
Massachusetts State Plumbing Code and Chapier�42 of the Generel Laws.
PLUMBER'S NAME LICENSE#o!`� IGNATURE
�P L� �P❑ CORPORATION�# PARTNERSHIP❑# LLC 0#
COMPANY NAME�! � Z�6/[.Q�ti/ ADDRESS L?i dJL LS7 7
CIN�f14-„°�v 1 c.Irf STATE�_ ZIPOJ��/S TEL�j`��''�']''���
FAX CELL EMAIL
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