HomeMy WebLinkAboutPlumbing PermitN
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY w- MA. DATE S� I PERMIT # 0 — 7�
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JOBSITE ADDRE / 0�6 OWNER'S NAME I�
POWNER
ADDRESS TEL FAX
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TYPE OR
OCCUPANCY TYPE: COMMERCIAL L EDUCATIONAL ❑ RESIDENTIAL ❑
PRINT
NEW: ❑ RENOVATION: ffl_"' REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO El
XTURES I FLOOR-
BSMT
11
2
3
4
5
6
I 7
8
9
10
11
12 I
13
14
ATHTUBROSS
CONNECTION DEVICE
t
EDICATED SPECIAL WASTE SYS
EDICATED GAS/OIL/SAND SYS
DEDICATED GREASE SYS
DEDICATD GRAY WATER SYS
DEDICATED WATER RECYCLE SYS
DRINKING FOUNTAIN
DISHWASHER
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
WATER PIPING
OTHER
INSURANCE COVERAGE: Ye
I have a current liability insurance policy grits substantial equivalent which, meets the requirements of MGL Ch. 142. Yes 0 No ❑
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: 1 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 BOX ONLY: OWNER ❑ AGENT ElSi
nature of Owner or Owner's Agent
I hereby certify that all of the details and infonnation 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 Pertinent rovision of Massachusetts State Plumbing Code and h ter 1 f the General Laws.
PLUMBER NAME
SIGNATURE
I LIC # v� MP JP ❑ COIRPORATION e ! PARTNERSHIP Flog LLC ❑ #
COMPANY NAME G !/h�ll�I ADDRESS:
CITY t 4 j STA ZIP -zO �65EEMAIL
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TEL CELL FaX
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