HomeMy WebLinkAboutPlumbing Permit � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY W ^ �/ A-/( WI MA DATE / PERMIT# I�DFL�`�"t�`��� �
JOBSITE ADDRESS f 7 In/l L cI wc� � p ��� OWNER'S NAME��� PO�I R
P T
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE 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 70 11 12 13 14 ���
� BATHTUB
\ CROSS CONNECTION DEVICE
� DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM
� DEDICATED GREASE SYSTEM
� DEDICATED GR4Y WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
� DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
y INTERCEPTOR(INTERIOR
� KITCHEN SINK
LAVATORY
ROOF DR41N
SHOWERSTALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING-MACHINE.CGMIN�6TJ4)p},
WATERNEfiLER ALL TYPE'� ' ` '
WATER PI I - `
OTHER '
_ ,, .
' — — - ---- ' INSURANCE COVERAGE:
I have a curreM liabil' insurance policy or its substantial equivalent which meets 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 POLICY� OTHER TYPE OF INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee dces no[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 ORAGENT
I hereby certify that all of the details and informatlon 1 have submitted or eniered regartling this application are true and accurete to the best of my knowledge
and that all ptumbing work and installations pertormed under the permit issued for this application wiil be in com 'aa wit all Pertine ro is� of the �
Massachusetts State Piumbing Code and Chapier�42 of the General taws, .
PLUMBER'S NAME p ,G�AGIf E LICENSE# /�SC� 51 U E
MP'� JP❑ CORPORATION�# PARTNERSHIP�# LLC�# '
COMPANY NAME p • C f�/4C kE ADDRESS � SR SS� F�/�S L�v
CITY f7FFri✓ic� STATE mA ZIP 0�6 y5 TEL .�D � "oZJ�Y— S36/
FAX CELL EMAIL I
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