PLUMBING PERMIT 4 SMITH STREET MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY SALEM -� MA DATE 19 PERMIT #
JOBSITE ADDRESS OWNER' S NAME
p OWNER ADDRESS T 64 C' _ C-
TEL ��/ FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL RESIDENTIALPRINT —1 y
11
CLEARLY NEW: [ RENOVATION : REPLACEMENT : PLANS SUBMITTED : YES NO ['
FIXTURES I FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 1 - -
CROSS CONNECTION DEVICE FJ
DEDICATED SPECIAL WASTE SYSTEM —
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM ----
� � DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER F
DRINKING FOUNTAIN `"
._- ,_-
FOOD DISPOSER
FLOOR / AREA DRAIN
INTERCEPTOR (INTERIOR) l
KITCHEN SINK
LAVATORY I f
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 insurancepolicy or its substantial equivalent which meets the requirements of MGL Ch . 142 . YES �0 ❑
p y
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY E BOND
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 0 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 tQrate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co rtinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws .
PLUMBER' S NAME PA LICENSE # % NATURE
MP EV JP ❑ CORPORATION [ # - PARTNERSHIP ❑ # LLC ❑# Chot-
COMPANY NAME $04 ADDRESS j
CITY STATE ZIP p I TEL 1? �. — &0 4 �
FAX CELL I EMAIL � �yV1I�i� /1,/� Ar7 � i-<� w-