AUG 2016 P&G TP-16-429 GAI
m Y MASSACHUSETTSUNIFORM 'R'RLtCA�TIbN FOR RERC�IIT TO PERFOR RL IING:� j ...
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TYPE OR OCCUPANCY TYPE. COMMERCIAL El EDUCATIONIAL RESIDENTIAL
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CLEARLY NEW: E RENOVATION:[] REPLACEMENT:� PLANS SUBMITTED: YES ] NOV
FIXTURES -1 _ 00R— -_- 5SM 1 2_ 2 4 5 6 7 a 9 � 10 11 12 13 14
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CROSS CCNNECTI(JriJ UE IICdF , __..__..._
DEDICATED SPECIAL WASrE SYSTEM � _..._.. _ _ _ ............. _....
DE—biCATE l.-GAS/01USAND SYSTEM _... _ ._
CIEMCATED GREASE SYSTEI�f
DEDICATED GRAY WA TER SYSTEM
I Et IE ATEI WATER RECYCLE SYSTEM � _
61SHWASHER
DRI'NKRNG FOUNTAIN
FOCO MSPOSER
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F'LtCOR�AREA EIRAl
lNT RCFPTOR{INTERIO.
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KITCHEN SINK f
LAVATORY _ 1 . ..
RO5 F DRANN _ _......
SHOWER STALL
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SERVICE MCP SINK
TOILET _. .... -___.._.. m._... .. _
UMNAL
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WASHING MACHINE CONNECTION �._. ........_. _WATER HEATER
ERALL TYPES _......
WATER PIPING
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�OTHER
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INSURANCE COVERAGE:
l have a current lilt ,Insurance pallcy or its substantial equivalent which meets the requirements cf' 1GL h."V Alm YES
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IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LUABILUTY INSURANCE POLICY OTHER TYP,E;OF BOND �
OWNER'S INSURANCE WAIVER. I acre aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts Genera' y g p' application wtaive this requirement.
I Lags,and that rn signature arr this,permit a
CHECK ONE ONLY; OWNER [] AGENT [�
SIGNATURE OF OWNER OR AGENT
I hw eby certify that aH of the details,and information I have submitted or entered regarding tN-uis appficek'on are true and accurate to the best of my kna�wiedge
and that aii plumbing work and Instaitatia�ns perforrrred under the perrnA issued for 6hrs appiocation 411 be in compliance with ail Pertinent provision of the
.. . General Laws. SIGNAT�
Massachusetts State PlumbingCode andChapter
PLUMBER'S NAME ���� 1,�2 of the �
-CCL�� ..._. LIC'ENSE _�. � �� �. .� .�.:.._ URE
MP JP CORPORATION K# Zk-kC:._ PARTNERSH&P C� _. _ ......�_ ... _ LLC _...._ .._..._.
CGNIPAIJY NANRE 1&..: �_.. ADDRESS_ ��..._ ..: JI _I _ . I E. . �. w._.._
CaTY n.. . _.__._...__ ._. _ STATE ZIP TEL w: w
FAX _ _.._ .. CELL „w_ EMAIL -. _IIW. °
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