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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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==1 F= � CITY ) / H/l ChJ pb "1 . MA DATE `Z I C( PERMIT# ��'l7J~ `1C) � .
JOBSITE ADDRESS I l V l b L G y OWNER'S NAME/9Sf-k � ?�
POWNER ADDRESS TEL FAX
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TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL-
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CLEARLY NEW:❑ RENOVATION>Er REPLACEMENT:❑ PLANS SUBMI I I ED: YES.❑ NU;
FIXTURES 7 FLOOR--I BS1v1 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 _
ROOF DRAIN
SHOWER STALL
I SERVICE/MOP SINK
i TOILET 5.t, 6-it
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER -
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES.B- NO ❑,
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW I' •_ ! ' ,''1=t
UABIUTY INSURANCE POLICY_— OTHER TYPE OF INDEMNITY 0 BOND l] 4,4
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OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage requiredby Chapter 142 f
the
it Massachusetts General Laws,and that my signature on this permit application waives this requirement.
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1:-.. CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
l I hereby certify that all of the details and information I have submitted or entered regarding this application are tru 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 co I' Pertinent provision of the
Massachusetts State Plu Code hapter 142 of the General Laws. IX,
PLUMBER'S NAME (L L 3 y�
LICENSE , . SIGNA
MP JP CORPORATION # PARTNERSHIP❑.# LLC El#3Z,.3
COMPANY/ NAME (7�CC 4 t ✓l r/ (96/1C� /` ADDRESS
CITY 4-4✓S 1-1-41 /04 STATEig > ZIP ,,7 TEL V -5/3
FAX Z y/{ -C CELL ,S/ Z4 /'1 EMAIL ?✓s--G va [It (7oA,2 CZS. ,n(
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