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.C\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �{
MI) CITY E.ou-;M O.XY1101)�'M� MA DATE�,,� •O, tl,;•ERMIT#/*-0f—hg'
JOBSITEADDRESS at VintitArd Si' J OWNER'S NAME J
OWNER ADDRESS ] Tarn FAX MUM
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL D RESIDENTIAC,,
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CLEARLY NEW:a RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NC
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 1111114!!!!!11111111II
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM 1
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER 1111111111 1111
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR IAREA DRAIN
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•ICNTEROR)
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ii! I a7SERVICEIMOPSINK ®. I - _
TOILET
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URINAL
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WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING I " ,II AI
OTHER i alel
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INSURANCE COVERAGE: - -
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE 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
'k'' - - Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and arate tot best of my knowledge
and that all plumbing work and installations performed under the permit Issued for this application will be in c with a I Perti t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Bruce Sison LICENSE# 32379 SIGNATURE
MPD JP❑✓ CORPORATION❑t4JPARTNERSHIP❑#MLLC❑#MM.
COMPANY NAME Sison Plumbing&Heating ADDRESS 1730 Washington Street
CITY Walpole STATE MA ZIP 02081 TEL 774-248-0063
FAX — CELL— EMAIL sisonplumbing@gmail.com
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