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MASSACHUSETTS UNIFORM APPLICATION FOR A E IT TO PERFORM PLUMBING WORK
n �/ J CITY �eSf �/q 6 r�oc��'1, MA DATE � ' PERMIT# , P��� t 1d
JOBSITE ADDRESS pOW'TS L4)i OWNER'S NAME
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL El RESIDENTIAL
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CLEARLY NEW:❑ RENOVATION:, REPLACEMENT:01 PLANS SUBMITTED: YES❑ NO LZ
FIXTURES 1 FLOOR--I 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/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM _
DEDICATED WATER RECYCLE SYSTEM _
DISHWASHER / .
DRINKING FOUNTAIN
FOOD DISPOSER
.
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK / _
LAVATORY J
ROOF DRAIN
SHOWER STALL / .
SERVICE/MOP SINK
TOILET /
URINAL
. j WASHING MACHINE CONNECTION _ _
WATER HEA I ER ALL TYPES
WATER PIPING _
OTHER _
.
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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 1NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELDIN r..,
LIABILITY INSURANCE POLICY Ile OTHER TYPE OF INDEMNITY 0 BOND I❑ /,/J
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage requirectWh(ager 4gpf the
1 Massachusetts General Laws,and that my signature on this permit application waives this requirement I
CHEC ZONE ONLY:_ _OWNER,D A4NT ❑
SIGNATURE OF OWNER OR AGENT
L-‘,I I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be i com Ha ce ' ll P ' nt provision of the
Massachusetts State Plumbing Code and Chapter 142 f the General Laws.
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PLUMBER'S NAME .J D,.f h � Ca� i) C LICENSE# 0O3 SIGNATURE
MP❑ JP(l] CORPORATION 0# PARTNERSHIP❑.# LLC❑#
COMPANY NAME C/we5O &c y$ fC- ADDRESS 1or� CQfr) CV 0,�,/�(,-R ICITY Ce Y1 f -1 ✓v/J1 STA TE ' ` A-- ZIP 0 a b 3 TEL SOY /7,367
FAX CELL EMAIL Qtr/Cfa ✓ t/ ,- ,/0'42;45 5 a.-
J c, mail ,C, J
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