Bldp-19-006819 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
=_1 CITY \Icy,- NI a c'T( MA DATE [—3 � PERMIT# � nr Tl"�O 6f/
JOBSITEADDRESS 3` I/")oI (f��'!1 ,I�lC OWNER'S NAME J '- '� —�.`�+
�
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMER AL❑ EDUCATIONAL ❑ RESIDENTIAL[g"-.--.."
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1. FLOOR—+ BSM 1 2 3 4 5 6 7 B 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
ROOF DRAIN
SHOWER STALL
f`7Cj tiP
•
I SERVICE 1 MOP SINK
s �
TOILET (j jIJN ;3 ill
URINAL
•
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING 1 _
OTHER
INSURANCE COVERAGE:
i 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 TH PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUC OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
It Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
it 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 in compliance l Pertin rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER' NAME .� r\ �,`t— LICENSE# 106 6. SIGNATURE
MP JP❑ CORPORATION❑# PARTNERSHIP 0.# LLC❑#
COMPANY N E t ADDRESS ?c) &A/ C l 2c
CITY Fes✓ ` STATE "" r ZIP D2c) TE 2- J •
FAX CELL EMAIL I vt, (e /0 CjM Ar� 1 M
\'7\
\)c)
\\N
-4
ck