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' lY � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY Y���s olr�7f MA DATE PERMIT#��'���JCTS�
,� � JOBSITEADDRESS/�L Lt/I.t/ilLOLJ 6'/J�'��� OWNER'SNAME�1ySJL�/?,
POWNERADDRESS TEL FAX
' `� TYPEOR OCCUPANCYTYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL�
PRINT
� CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:,� PLANS SUBMITTED: YES❑ NO�'
FIXTURES 7 FLOOR� BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
'�j BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOILISAND SYSTEM
� DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
� DISHWASHER
DRINKING FOUNT y
FOOD DISP
FLOOR/AR N�P'
INTERCEPT (IF1TE
KITCHEN SW j ��
LAVATORY � .—���CZTt�n '
ROOFDRAIN F, u j�iCti�"
SHOWER STALLI sv �
SERVICE/MOP INK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATERHEATERALLTYPES
WATER PIPING
OTHER
1 C
� INSURANCE COVERAGE:
I have a curzen[liabili insurance policy or its substantial equivalent which meeu the requirements of MGL Ch.142. YES� NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLJCY � OTHER iYPE OF INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WANER: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 permi[applicaUon waives this requiremen[.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and infortnation I have submitted or entered regarding this application re e an cy te to the best af my knowledge
. � and that all plumbing work and installations perfortned under the permit issued for this applicatlon will be i co lianc R II PertineM provision of the
. Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE#���� SIGNATURE
MP❑ JP❑ CORPORATION❑# PARTNERSHIP❑# LLC 0#
COMPANY NAME����� ADDRESS � �� �� �S 7�
CITY t�S�u t G� STATE� ZIP�S TEL S'�o��3��lb vY
FAX CELL EMAIL
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