PP-65549 ' ' 'OUTH 1LDING DEPARTMENT RECEIPT 35349
_. :`.,08-9t 1820 FAX: 508- 0-1838
,IJ , v
Nal1 ( 't - %
1i'� - .� !r• -"Owner: '-" Date f f
Job Location. ._. �`,..: ;,€ -OF is�p pn
R' FF! EE
000LLECTO
Description General'Ledger#'s � PI#2 4 zoiz Amount
Building & Building Misc. 01000-44105
Electric,.--. 01000-44106
C . /: 7 r ,_,k
Plu 'Gas 01000-44107 2 4 '
Trench Safety 01000-44129
Other Department Revenue 01000-42420
White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received By /i
THIS IS NOT A PERMIT'ILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS
�
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING VVORK
-103
_----------------
_
C|TY�T�~ ./�~�_y?��lLl�-i- _^_ ____�___i MA DATE0 / -� !PERM|T#
�"e�*' --- -- ----------------'- -
JO8S|TEADDRESS ' -~J ! OWNER'SNA�E u~
.-~~� ~~.'"".~�^-=��"=_"�=*~�^"
OWNERADDRESS '- - -- --- TEL |------'
J� - �� --�='��^^c�-'���-��^�^^-�'^'' ���� _����azxa��' '`'`�_____'--.__/
TYPE OR OCCUPANCYTYPE COMMERCIAL EDUCATIONAL EDUCATiONAL i__' RESIDENTIAL��'
PRINT
CLEARLY NEW:7-� RENOVATION:' - REPLACEMENT:��' PLANS SUBMITTED: YES' NO.-V
FIXTURES -1 FLOOR- ooM 1 c 3 4 | 5 6 7 o n 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OlUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK �_= !�_ -
LAVATORY ' �� ----------
��--? ---` -
-
nuurunxo,
SHOWER STALL
SERVICE MOP SINK
URINAL
-AVASHING MACHINE CONNECTION
V�,IATER HEATER ALL TYPES
M\TER PIPING
~' INSURANCE COVERAGE:
|have o current liability insurance policy uv its substantial equivalent which meets the requirements ofMGL Ch.142: YES NO
IFYOUCHECKBo YES,PLEASE INDICATE THE TYPE OF COVERAGE 8Y CHECKING THE APPROPRIATE BOX BELOW
r�
L�B|UTYINSURANCE POL!CYF�
uo OTHER TYPE OF INDEMNITY L� BOND [7
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: UVV0ERr� AGENT
--
S/SNATUREOFOWNERORAGENT --
/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 u40e,-
mpoa / o provision Maooacou,e000��p|ummnoCode and cxa�a,142nfm000no�|Lawm'
��l ---- m°�'PLUMBER.SNAMEm~�y����� �� �\ � �L|CENSE ���� -~ SIGNATURE
P�� `~--
��
W JPoc/ CDRPORAT|ON (PARTNERSH|P�7# LLC--'
-
/ COMPANY NAME
� ==,����=�*�`�-�x^-ws���/
CITY 7 ^ | ZIP TEL
FAX � 'CELL �K��|L | ----
_�
�
^
N.
N
pf
z
e1 0 -
L ��
c:3.-
❑
4 >- :\\C
1 ,, o
" ) W o
N :� z
Lu
W C
N
/ r
0 z
p f r
W
U
J
a.
d
cn Li.!
= W
I- Li- I
CA
z v
z
0
U
W
z
c.
C7