HomeMy WebLinkAboutPlumbing Permit � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBWG WORK
CITYT P,�^JJJ�i�l1� MA DATE ���b=l� PERMIT#1��-��'I�`o0/
JOBSITE ADDRESS���_ts�Vi��� OWNER'S NAME_���/,Q jC�—
� P OWNER ADDRESS TEL FAX
� TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL�
� PRINT
� CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITfED: YES❑ NO❑
C FIXTURES 7 FLOOR� BSM 1 2 3 4 5 6 7 8 9 10 it t2 t3 14
�
� BATHTUB
� CROSS CONNECTION DEVICE
i DEDICATED SPECIAL WASTE SYSTEM
� DEDICATED GAS/OILISAND SYSTEM
� DEDICATED GREASE SYSTEM
� DEDICATED GRAY WATER SYSTEM
� DEDICATED WATER RECYCLE SYSTEM
� DISHWASHER
� DRINKING FOUNTAIN
FOOD DISPOSER
� FLOORIAREADRAIN
INTERCEPTOR INTERIOR
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SI K
TOILET
URINAL BUILDING D EN �
WASHING MACHIN
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
i have a current liabili insurance policy or its substantial equivalentwhich meets the requiremeMs of MGL Ch.142. YES� NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANGE POLICY!'�( OTHER TYPE OF INDEMNITY ❑ BOND ❑
/�"�
OWNER'S INSURANCE WANER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts Generai Laws,and that my signature on this requirement
0
CHECKONEONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT St i PO�
I hereby certify that all of the details and informaEon 1 have su mitted or entered regarding th application tru nd ccurate to the best of my knowledge
and that all plumbing work and installations performed under e pe ' ' �f��ppii �ion will b n i with all Pertinent provision of the
Massachusetts State Plumbing Cotle and Chapter 142 of the ene ,Y ,
RLUMBER'S NAME LICENSE# ���� SIGNATURE
MP� JP❑ CORPOR4TION 0# PARTNERSNIP❑# LLC❑#
COMPANY NAME �iPfl/h hO.C/))�� ADDRES$ �#�iC _(�71
CIT�Lr��"z�- STATE� ZIP �L6�� TEL SIJ� "���d�__
FAX CELL EMAIL
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