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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
—.1— CITYfirn}di pier MA DATE 41cA 1 d(-43 f PERMIT# Bi-OP-2H-.4-I(''
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JOBSITE ADDRESS L,J3 1 P j,d2, n4 OWNER'S NAME/v�"�
POWNER ADDRESS SRYYNj TEL FAX_•------.
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:0 PLANS SUBMITTED:YES 0 NOA
FIXTURES 7 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/OILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR l AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
i LAVATORY I •
ROOF DRAIN
SHOWER STALL I Y
SERVICE/MOP SINK
TOILET
I I _
URINAL _ I
I WASHING MACHINE CONNECTION I ' I111
WATER HEATER ALL TYPES I •
WATER PIPING 1.
OTHER I - -
I _
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTI INSURANCE POUCI 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
i Massachusetts General Laws,and that my signature on this permit application waives this requirement.
2 CHECK ONE ONLY: OWNER❑ AGENT❑
SIGNATURE OF OWNER OR AGENT
1-11 I hereby certify that all of the details and information I have submitted or entered regarding this application are tru nd acc t to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in cory lance 'R a ertinent provision of the
Massachusetts State Plumbing Code and chapter 142 of the General Laws.
PLUMBER'S NAME/SOrrte 7t)5l k LICENSE#3)97! . SIGNATURE
MP 0 JP1,21
Q O-RPPORATION 0# PARTNERSHIP/ 0 LLC 0#
COMPANY NAME,i GT Il1th IL 14 6/1( ADDRESS e1 E koc-
CITY i9'ruP(1, J STATEM!4 ZIP `/ E13'0S 77t /&
'
FAX CELL EMAIL Y Oti'G1lis CL)
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT [ j
FEE: $ PERMIT #
PLAN REVIEW NOTES