FEB 2016 P&G TP-16-83 APP MASIACHOSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBIN WORIK
CITY MA DATE 7 PERMIT#
JOBSITE ADDRESS OWNER'S NAME
OWNER ADDRESS !a."I 4A TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL E] RESIDENTIAL
PRINT
CLEARLY NEW:Ej RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YESO NO
FIXTURES I FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 1 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of IVIGL Ch. 142. YES Er-—NO—El
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY J2-' OTHER TYPE OF INDEMNITY F BOND El
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 F-1
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have submitted or entered regarding this application are t a rat to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application-will be i p a e 11 ert ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws, ❑
PLUMBER'S NAME J )j 4614 0-) LICENSE# SiGNATURE
MP JP❑ CORPORATION El# PARTNERSHIP LLC D#
COMPANY NAME ADDRESS
CITY ?Ck ZIP TEL
FA)Q2 CELL!]_7�,A EMAIL .-S ('61 Yk