HomeMy WebLinkAboutPlumbing Permit ' � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
L PERMIT# ��/�P'/y=G'Op�
CITY �1/Wl()Zl �'—� MA DATE l CJ^2 U-1 �
\ JOBSITE ADDRESS �� � � �-f �� OWNER'S NAME �LI �%7
� P OWNER ADDRESS � � � TEL FAX
� TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑
� PRINT /
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:[� PLANS SUBMITTED: YES❑ NO❑
�� FIXTURES 1 FLOOR� BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
� BATHTUB
CROSS CONNECTION DEVICE
Q� DEDICATED SPECIAL WASTE SYSTEM
p DEDICATED GAS/OIVSAND SYSTEM
DEDICATED GREASE SYSTEM
� DEDICATED GRAY WATER SYSTEM
� DEDICATED WATER RECYCLE SYSTEM
DISHWASHER ,
DRINKING FOUNTAIN ,'-.,`'.
� FOODDISPOSER ``�
O FLOOR/AREA DRAIN
INTERCEPTOR INTERIOR) E: '
KITCHEN SINK „ ,.^�,�
�Q LAVATORY , �._, 1�
.� ROOF DRAIN { 4'F �� � , `L
� SHOWERSTALL „ .
SERVICE/MOP SINK
� TOILET .� '� ,
� URINAL �� ���/
WASHING MACHINE CONNECTION '
� WATER HEATER ALL TYPES
WATER PIPIN�
OTHER
-G U ? /� Ci
INSURANCE COVERAGE:
I have a current liabili insurance policy or its subs[a 'al equivalent which meets the requirements of MGL Ch.142. NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW -
LIABILITYINSUR4NCEPOLICY OTHERTYPEOFINDEMNITY ❑ BOND ❑ ���� 2� 2014
OWNER'S INSURANCE WANER:I am aware tha[the licensee dces no[have the insurance coverage required by Ch ter142 of the
Massachusetts General Laws,and that my signawre on this permit application waives this requirement. H��TH DEPT.
CHECK ONE O�Y: OWfdER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submilted or entered regarding this application a rue to best of in ed
and ihat all plumbing work and installations perfomied under the pertnit issued for this appliwtion wiil be in m ce wi I M provis' .
Massachuselts State Plumbirg Code and Chapter 142 of the Caeneral Laws. �
PLUMBER'S NAME ��J � � {�'/ K�-�`-(��vi Vi o �JCENSE# ���I SIGNATURE
MP� JP❑ CORPORATION 0# � PARTNE SHIP�# LLC�y'#,j'����
COMPANY NAME � 172_Lt/ I ���i1_W>�ADDRESS � J 3 C��i/7//Yr�Q �' C�a ( f 7�"
CITY !�v/��� /7�� STATE +�� � / ZIP Z� EL,� W` � f - C�0[
FAX CELL EMAIL
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