FEB 2016 P&G TP-16-97 APP MASt CH USETTS 1UN I FORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY PERMIT#
MA DATE 2
JOBSITE ADDRESS 1, OWNER'S NAME ,/
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0--
PRINT /20'
CLEARLY NEW: ❑ RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES❑ NO
FIXTURES I FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK .0
TOILET
URINAL
WASHING MACHINE CONNECTIONF—
WATER HEATER ALL TYPES
0
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of IMGIL Ch.142, YES 0 NO EJ
IF YOU CHECKED,YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND 17
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 F 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 true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
z,
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# SIGNATURE
MP F-1 ip D......... CORPORATION El# PARTNERSHIP LLC
COMPANY NAME ADDRESS
CITY ZIP
STATE TEL ts
FAX CELL EMAIL