FEB 2016 P&G TP-16-85 APP ( d ks-,
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
E PE CITY........... `'` MA DATE �_ PERMIT
JDBSITE ADDRESS 1a y"
OWNER'S NAME .�
OWNER ADDRESS � � � TEL ..�_. FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL RESIDENTIAL
PRINT .. .....
CLEARLY NEW: F-1 RENOVATION:F-1 REPLACEMENT: Ej PLANS SUBMITTED: YES❑ NO
.......................
FIXTURES -1 FLOOR— BSM 1 2 3 4 5 6 7 5 9 19 11 12 13 14
BATHTUB
CROSS CONNECTPON DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR INTERIOR)
KITCHEN SINK
LAVA
TORY _
_._ __I..._......_..�_ .._ _........_.............._.._
ROOF DRAIN
SHOWER STALL _.
SERVICE I MCP SINK
___. ..�.._____..____........
....
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES_.........__.d._.
WATER PIPING
OTHER
_ INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch, 142. YES ICJ NO Ej
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLIC" Jl OTHER TYPE OF INDEMNITY ❑ BOND C
y
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 ❑ AGENT [�
SIGNATURE OF OWNER OR AGENT
V hereby certify that all of the detadls and information I have suLmii ed of centered regar' ing this ap,plicaticm are true and accurate to the best of my knowledge
and that aV plumbing work,and Inslal'latlons performed under the permit issued for this application wild be in compliance with all Pertinent provision of the
Massachusetts State PNumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME. LICENSE# 7 __ .....m..__ SIGNATURE
MPi JP El CORPORATION # PARTNERSHIP❑# LLC
COMPANY NAME tt .. �.�_ ADDRESS
_._...._._._......_........_ _ _ _...._._..
CITY_ — STATE" " _ ZIP � ?.._._ TEL
CELL _ . "'FAX__ EMAIL
_. __ __._ _.__�.