AUG 2016 P&G TP-16-426 APP ?
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C S � IFO A F"Lil TIO FOR,A PERMIT T PE FCa PL IN ILK
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MA DATE � PERM M
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SS I OWNER'S NAME l "
SS TEL FAX
PREOOCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
CLEARLY' NEW El RENOVATION krREPLACEMENT; PLANS SUBMITTED: YES E NO 0
FIXTURES I FLOOR- IBM 1 1 2 3 4 5 6 7 8 9 10 11 12 13 114
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR INTERIOR
KITCHEN SINK
RRF
RY
ROOFRAIN
SHOWER STALL
....... .. .. ... ____.. ._....._
I MOP SINK
G MACHINE CONNECTION
. .... ..
HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liabili insurance policy or its substantial equivalent which meets the requirements of M'GL Ch.142, YE NO
IF YOU CHECKED YES„PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE,APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ® SOND El
OWNERI S INSURANCEWAIVER:I am aware that the licensee does net 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 GENT
SIGNATURE OF OWNER OR AGENT
i hereby certify that all of the details and information I have submitted'or entered regarding this application a a d accuraite a bes knowledge
and that atl plumbing work and installations pertforftl4ofthLGenerall-aws,
ndee permit issued for this application Mill mrli n with a I Pert' ent v' an of the
Massachusetts State Plumbing Cade and Chat
PLUMBER'S NAME
LICENSE#I _ SIGNATURE
MP JP CCIRPCIRATIO # ._ PARTNERSMIP E] LLC
COMPANY NAME ADDRESS t
1/1 e�W-4)j&o
CITY STATE ZIP T Lin
FAX �_ . CE 7 1" EMAIL t �