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MASSACHUSETTS UNIFORM APPLICATION FOR A PE IT TO PERFORM PLUMBING WORK
--"1— CITY S (fjj�I t MA DATE PERMIT# }i P- z3 .I"�,r/
JOBSITE ADDRESS /2 4 ,w, OWNER'S NAME l_:( •
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[11_
PRINT
CLEARLY NEW:[/RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0❑
FIXTURES 7. FLOOR-4 BSIv1 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 l
ROOF DRAIN
SHOWER STALL
SERVICE 1 MOP SINK
TOILET
URINAL
. j WASHING MACHINE CONNECTION i' C . V E D
WATER HEATER ALL TYPESWATER
OTHER PIPING SEP O ! LU 3
[BDINGDEPARTMNTJ
IL
INSURANCE COVERAGE: ,�..,�
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES l� N0 ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF 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
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 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 withit all Pertinent provi ion o e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / �J �(�ZGd2C
PLUMBER'S NAME /J t t( ��UCkS LICENSE#`( ,
SIGNATURE
MP ❑y JP❑ CORPORATION
/� ADDRESS L
CITY h%)11-i'ov STATE l/644 ZIP TEL
FAX IQ f(?) CELL 36 7 :3MEMAIL ,f-/U ,
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