32a-169 (6) cjy,a /5?-('4�! 1`7 V
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBINGWORK
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CITY Lk&,A MA DATE PERMIT �` ^`�—J`T
JOBSITE ADDRESS ��w�e� vnr'f 2❑ OWNER'S NAME
POWNER ADDRESS 7i �1.� TEL -36q- t7z ]FAX®
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL9,,,_
PRINT
CLEARLY NEW: RENOVATION:O REPLACEMENT:,1 . PLANS SUBMITTED: YES N0[X
FIXTURES Z 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/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER -117
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) i
KITCHEN SINK
LAVATORY ^�
ROOF DRAIN _
SHOWER STALL l
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES VE
WATER PIPING
_
OTHER ^
1
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES-J, NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY)� 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 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 '11 be� nce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws-
PLUMBER'S NAME'-7w 1 _❑LICENSE#L'_a C�3 i� SIGNATURE
MP❑ JF-xj CORPORATION PARTNERSHIPQ# LLC❑#F�
COMPANY NAM�j wvr� � �1vM ADDRESS r3
CITY irRL,z-S,, ,� STATE ❑ ZIP TEL
FAX CELL EMAIL b�:)i> y nj �7 ni,�1,�,,v r C oy\'�