AUG 2016 P&G TP-16-436 MASS,A,CHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
MA DATE r e'
CITY/TOWN M�� PERMIT�_
JOBSITE ADDRESS t n �...;> OWNERS NAME
OWNER ADDRESS a I TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL Ej RESIDENTIAL /
PRINT
CLEARLY NEW RENOVATION: "' REPLACEMENT PLANS SUBMITTED: YES -NO
FIXTURESFLC7OR 9 M 1 2 3 4 6 6 7 6 91 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE �
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OILISAND SYSTEM 4-
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER e "
DRINKING(FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN':
-
INTERCEPTOR(INTERIIOR _.
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK
_ ....._ . ...__...
TOILET
URIINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING _
OTHER
INSURANCE COVERAGE:
I have a current Liabifityjnsurance policy or its substantial equivallent which meets the requirements of MGL Ch. t42. YES NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY)[jq— OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:II am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Lags,and that my signature on this permit application waives this requirement
CHECK ONE ONLY; O'I 'N'ER Ej AGENT 0
SIGNATURE OF GINNER OR AGENT
N hereby certify that all of the details and information I have submitted or entered regarding th s application are true and accurate to the Crest of my known edge
Massachusetts State Plumbing Code and Chapter 1�42 of the General Laws will be in co Banc with INI Pertinent provision of the
and that al. or this application _._.._.
i lumbin wti+ork and installations performed under the permit issue' .._...
PLUMBER'S NAME Yf r LICENSE , 3 c G TU� RE
MP 0 JP CORPORATION E]# PARTNERSHIP # LLC _.
COMPANY NAME " .. ADDRESS
CITY — - STATE , ZIP
FAX _ CELL_ �_ _ _ EMAIL