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� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WO K
CITY i_ fl��(.a U"�� MA DATE , O�- Z���PERMIT#1,�-�/a O(o"�C/l6
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J08SITEADDRESS �� S��'L� J�'� �UCICL,(7�.OWNER'SNAME '�6AN� �Dl���
P OWNER ADDRESS__(O� ����� � F'� �d e��FEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[��
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLAGEMENT:�^ PLANS SUBMITTED: YES❑ NO
FIXTURES 7 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/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAW
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHWE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
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INSURANCE COVERAGE: :
I have a current liabili insurance policy ar its substantial equivalent which meets the requirements of MGL Ch.142. YES� ❑ '
IF YOU CHECKED YES,PLEASE INDICATE THE E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY � OTHERTYPE 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 tru .a d curate to the b s of m knowledge
and that all plumbing work and installations perforrried under the permit issued for this application will be in comp a e h all Pe ' ovisi
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER' AME�GTr2�}I� �.�`�.e� LICENSE# (� f J� SIGNATURE
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