AUG 2016 P&G Permits TP-16-437 C12,
rOWNER
SACI°USE T'S UNIFORM APPLICATION
� �N I�t)I PERMIT 7'C�PERFORM PLUMBING OIRK.
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A DATE ✓ PERMIT 7
DRESS L'' ' OWWN'ER'S NAME
DRESS TEL FAX
PTY
OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
/ ' _.
CLEARLY NEW: RENOVATION:JK REPLACEMENT: PLANS SUBMITTED: YES NO
FIXTURES I FLOOR— 'BSM 1 2 j 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION'DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM � �
DISHWASHER
DRINKING FOUNTAIN a
FOOD DISPOSER _ w
FLOOR I AREA DRAIN
INTERCEPTOR INTERIOR
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL w
SERVICE I MOP SINK F
TOILET _.._
URINAL _ _m
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE- TIE
I have a current liabilq insurance policy or its substantial equivalent which meets the requirements of MIGL Ch.14 . YES�g NO
IF YOU'CHECKED YES„PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 6 OTHER TYPE OF INDEMNITY 0 BOND Ej
OWNER'S INSURANCEWAIVER: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
SIGNATURE OF OWNER OR AGENT
I hereby certify that ail'of the devils and information I have submitted or entered regarding this application are true and accurate to the best of imy knowwledge
and that all,plumbing work and installations performed under the permit issued for this application will be in7. with all P rtinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws,
PLUMBER'S NAME 1�- LICENSE l SI NA�TU RE
MP CI JP CORPORATION A—. PARTNERSHIP[]PARTNERSHIP[]# LLC
COMPANY NAME ell ADDRESS S ' .,
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CITY w ' (r STATE / Z' ;SIP � � (� _ TEL
FAX
CELL EMAIL