HomeMy WebLinkAboutPlumbing Permit � MASSACHUSETTS UNIFORM APPLI PERMIT TO PER ORM PLUMBING WORK
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CITY_ �/�-(2 r� f,' �;Ll�—
ERMIT#��-/�'—+��'r�'„'�
JOBSITE ADDRESS�/ Co��o.,� c'� _ OWNER'S NAME ��'��^C �
POWNER ADDRESS _ TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ � ❑ RESID NTIAL'�'
PRINT
CLEARLY NEW:❑ RENOVATION:� REPLACEME�' PLA S SUBMITTED: YES❑ NO❑
�
� FIXTURES 7 FLOOR–+ BSM 1 2 3 7 8 9 10 11 12 13 14
,� BATHTUB , (
� CROSS CONNECTION DEVICE
� DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM —�
� DEDICATED GRAY WATER SYSTEM
� DEDICATED WATER RECYCLE SYSTEM
" DISHWASHER
DRINKING FOUNTAW
.� FOOD DISPOSER
� FLOOR/AREA DRAIN '
INTERCEPTOR INTERIOR) ; —
� KITCHEN SINK
S LAVATORY -
t� ROOF DRAIN
SHOWER STALL
eJ SERVICE/MOP SINK
r� TOILET
URINAL �
��. WASHING MACHINE CONNECTION i
WATER HEATER ALL TYPES
WATER PIPWG
OTHER �� �� �, , -
INSURANC
I have a current liabilitv insurance policy or its substantial equivalent �equirements of MGL h.142. YES�j' NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHi �OPRIATE BOX BELOW
LIABILITY INSURANCE POUCY � OTHER TYPE OF I�: BOND ❑
OWNER'S INSURANCE WAIVER:I am aware ihat the licensee does nc �ce coverage require by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit ap ;his requirement.
CHECK ONE 0 LY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or ente application are true and ccurate to the best of my knowledge
and that alI plumbing work and installations performed under the permit issuc �n will be in compliance ith all Pertine ro ' ' n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. '���`
PLUMBER'S NAME �, ���C�'� LIC ?� SIGNATURE
MP� JP❑ CORPOf2ATI0N�# =RSHIP 0.# LLC�#
GOMPANYNAME__ �C`�R�Cfi's� 3 j�- ���N ,,•
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CITY �'I.7 �nl,n11�� STA E �. � � � �
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J _ ��Y°- �.3�/
FAX �
CELL � O ZI�fS '
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� f:,ALTH DLPT. �� "� �f�;�_ , ' �.. ,� ,�
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