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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY `�/ o,6 MA HATE `" �l� PERMIT#
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JOBSITE ADDRESS �J / Z66"L S �l(f/ �(/((�lO/ OWNER'S NAMEW 56
OWNERADDRESS TEL FAX
OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL
NEW: ❑ RENOVATION: z REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO
FIXTURES 7 FLOOR—
BSM
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2
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4
5
6
7
8
9
10
11
12
13
14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR / AREA DRAIN
INTERCEPTOR INTERIOR
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/
7
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO ❑
IF YOU CHECKED YES, PLEASE INDICATE TH7 TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE 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,
CHECKONEONLY: 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 true and accur a to the as of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be in compl' wit Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMB 'SNAME (� l��Vy'yOd%V LICENSE# �B�O SIGNATURE
MP JP El` CORPORATION El# PARTNERSHIP ❑ # nnLLC I� #
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C0MPANYNAME/���V -10"ZJ O CG 6,; ADDRESS 1A wa or
CITY L]F/�/ LI�/ ! STATFW- ZIP c9d 6v TEL. �� r ,AEW
FAX CELL EMAIL jAN OR7 i5
�7:?j 3'RTfv NT a IV
ROUGH PLUMBING INSPECTION NOTES
BELOW FOR OFFICE USE ONLY
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE:
PERMIT #
PLAN REVIEW NOTES
FINAL INSPECTION NOTES