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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
' , CITY ' -/1&"`- MA DATE PERMIT#&0P-Ig1 721:),1 /
�„. JOBSITE ADDRESS_ )1 17�= (-- 1'(,-vT 1—' OWNER'S NAME (i�'c%: .,_ \ f ,.,,,, `,
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL J-
PRINT
CLEARLY NEW:E. RENOVATION:❑ REPLACEMENT: ❑ PLANS SUBMI I I LD: YES❑ NO❑
FIXTURES 7. FLOOR--' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB i
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM - l __I
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER 1
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK /
j LAVATORY ;1, /
ROOF DRAIN
SHOWER STALL /
SERVICE/MOP SINK
TOILET / /'
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❑ NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POLICY V 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
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
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 in compliance with all Fr inent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. \
PLUMBER'S NAME LICENSE# ((e357
ATURE
MP Er JP❑ CORPORATION❑# PARTNERSHIP 0.# LLC 0#
COMPANY NAME I( 'C. /" /6 I. S ADDRESS S r� '`ti
CITY (J . `.) A.A'CI 11 STATE Pt ZIP e2 / 20 TEL
FAX CELL EMAIL z.vey-
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ I � �b G
FEE: $ PERMIT# Z-. 7 2/
PLAN REVIEW NOTES (/
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