AUG 2016 P&G TP-16-427 APP MASSAC11USETTS NJhINNb NeNtr iN I C) NT PENS Nct) UM'BI''NG'W'WORK
CITY/TOWN MA DATE
N'ERMIT /
JQ'SSITE ADDRESS a
OWNER'S NAME'
OWNER ADDRESS TEL.
FAX
FrE�RjtCCIJPANCY TYPE COMMEICIAL EDLICATIfNAL RESIDENTIALLLE'A►RLNEW: V RENOVATION:0 REPLACEMENT; PIONS SUBMITTED: YES NO
FIXTURES I FLOOR BSM 1 2 3 4
BATHTUB5 6 � 8 9 1tl t 1 12 13 14
CROSS CDNNECTIt7N DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASICIILISAN'D SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY MAT=SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING,FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR INTERI'17R
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL .. _...... .� _.._ry
SERVICE SItV
TOILET
URINAL _
ASHING MACHINE CONNECTION
WATER NEATER ALL TYPES
WATER PIPING
DITHER
INSURANCE COVERAGE:
I have a current NPat Insurance policy,or its substantial equivalent which meets the requirements of MGL Ch.14 , YES NU �]
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE EOX EELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee foes not have the Insurance coverage required by Charter 142 of the
Massachusetts General Lays,and that my signature an this permit application waives this requirement.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY OWNED ED AGENT
t hereby certify than all of the details and Irufarrnatiaan I have submitted or entered regarding this application are true and accurat to the be t of my k awledge
and that all plumbing work and installations performed under the permit issued for this applacatian wvill be in cnmpll ce with all a ent rov sion
Ma�ssachusetts'S to Plumbing Code and Chapter 142 of the General Laws. � e
PLUMBER'S NAME ""'
LICENSE __ IGNA PR
M'P El J'P COR'PORA IoN # PARTNERSHIP( LLC
COMPANY NAME ADDRESS
CITY - a
S _ zip _ _ TEL
FAX ._ __ CELL '' EMAIL < � � ,