HomeMy WebLinkAboutP-14-039MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
MM;
CITY JL4 DATE PERMIT#
JOBSITEADDP.ESSAOVVNER'SNAME
POVJNERADDRESS
TEL FAX
TYPE OR
1/
OCCUPANCYTYPE: COMMERCIAL ❑ RESIDENTIAL
PRINT
CLEARLY
Y
—/[I[IEDUCATIONAL❑
REPLACEMENT: ' PLANS SUBMITTED: YES NO
NEW: ❑ RENOVATION: ❑ tom
FIXTURES FLOOR- SSIdT 1 2 3 I 4 5 6 1 B 9 10 11 12 13 14
BATHTUB I I I I
CROSS CONNECTION DEVICE I I I
DEDICATED SPECIAL WASTE SYS I I I I I I
DEDICATED GAS/OWSAND SYS I I
DEDICATED GREASE SYS I
DEDICATD GRAY WATER SYS I I I
DEDICATED WATER RECYCLE SYS
nn
DRINKING FOUNTAIN
DISHWASHER I IIN I
FOOD DISPOSER I I �'li RI rrl�
FLOOR I AREA DRAIN
INTERCEPTOR (INTERIOR) i I
KITCHEN SINK
LAVATORY
ROOF DRAIN" I I
SHOWER STALL I I I I
SERVICE I MOP SINK
TOILET I I
URINAL
WASHING MACHINE CONNECTION I I I I I
WATER HEATER ALL TYPES I I
WATER PIPING
OTHER I I I
I
INSURANCE COVERAGE:
1 have a current liabilityInsurance policy oris substantial equivalentwhich, meets the requirements of MGL Ch.142. Yes ❑ No ❑
IF YOU CHECKED YES, PLEASE INDICA�TE/T�iE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY LGJ 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
CHECK ONE BOX ONLY: OWNER ❑ AGENT ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) regarding this appfi on are true and accurate to the
best of my Knowledge and that all plumbing work and installations performed under the permit ued for this application will be In
compliance with allm
Pertieify t/ pro7ion of th Massachusetts State Plumbing Code and Chapter 14 the General Laws.
PLUMBER NAME /�lP% / �Q SIGNATURE
LIC # z!�—�-/s MP ❑ JP CORPORATION ❑ # PARTNERSHIP [I# LLC ❑ #
07-k�
COMPA�N NAME ADDRESS-
CI�Zi / STATE P L'
TEL C QfH �� FAX
ROUGH PLUMBING INSPECTION NOTES I THUS PAGE FOR INSPECTOR USE ONLY
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT II
PLAN REVIEW NOTES
FINAL HNSPECTION NOTES