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SACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
TNEW. RENOVATION:E3
MA DATE 9Y2412020 PERMIT 0?202)- 01 18 rove St OWNER'S NAME William Tumumsha
P� TELOFAXV ORERCIAL❑ EDUCATIONAL ❑ RESIDENTIALQC LY REPLACEMENT:Q PLANS SUBMITTED: YES❑ NO[-]
FI REST OR-' BW 1 2 3 4 5 s 7 s 9 70 77 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOILISAND 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
SERVICEIMCPSINK 1
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES I I _
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES Q NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Q 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 cedifythat all of the details and information I have submitted or entered regarding this application are We and accurate to the beat of my knowledge
and that all plumbing work and installations performed under the permit issued for this application Will ba in compliance with all Pediment pmvision of the
Messachusans State PlumbiW Code and Chapter 142 of the General Laws.
PLUMBER'S NAME I Paul Graham LICENSE# 12322 SIGNATURE
MPQ JP El CORPORATION❑# PARTNERSHIP❑#=LLC❑#��
COMPANY NAME I Paul's Plumbing&Healing ADDRESS FRO.Box 303
CITY1 Huntington ISTATE® ZIP 01050 TEL 413.238-0303
FAX CELL 41382&2745 EMAIL paulsplgxhtg®aol.com
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