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MASSACHUSETTS UNIFORM APPLICATION FOR A ER IT TO PERFORM PLUMBING WORK
CITY_ � /`id 0 V Tl/1 MA DATE 11 �� PERMIT# 2.3 O
JOBSITE ADDRESS 7 /5 U,v,kJ c_11 OWNER'S NAME
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO 0
FIXTURES I. FLOOR—I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM w s m
DEDICATED GASIOIUSAND SYSTEM '3z
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM NOV 05 2O5
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER _
DRINKING FOUNTAIN t8t�lt u 2v A r
FOOD DISPOSER — _ �E�,•u
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:
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 TYP F COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND 0
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 com lance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE#/R,§ SIGNATURE
MP JP 0/- CORPORATION
0111# PARTNERSHIP 0# LLC❑#
I -TCOMPANYNAME P�c ADDRESS ,..5 / V1/771V10
CITY YPtiYv I STATE `� 1 ZIP o 6 / 5 TEL
FAX CELLO(% 19EMAILbC1c//a Y )1f v u l03 E7"oqi