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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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'- CITY w r9✓LPLA MA DATE I .., / Z L PERMIT#A4pP`g Oo n/7
JOBSITE ADDRESS 7 (9 V A;. CC! ,J*C.-/I PL)` (;ie)WNER'S NAME i'`�1 f' i'44'
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIO ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: D REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR 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
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
. WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES j
WATER PIPING
OTHER
I
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO ❑
! IF YOU CHECKED YES, PLEASE INDICATE THE F 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
1` Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
'.<1 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 with II Pertinent ovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 77
PLUMBER'S E LICENSE# ��✓ �� SIGNATURE
MP JP❑ CORPORATION 0# PARTNERSHIP❑.# LLC❑#
COMPANY NAME Q vc,. I me-ok Cy 5 ADDRESS CITY (A) STATE ill`4-- ZIP D s 71 TEL 5 Op2 /4/ r'
FAX CELL 7 7 g > U EMAIL itu- l' j' u-c.�c2-4 S�S3 0
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES