TP-16-428 21 CROSS STREET m
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY MA DATE PERMIT# . -,,2`.
JOBSITE ADDRESS w.rti.0 ;° OWNER'S NAME
OWNER ADDRESS _ TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL F-1 EDUCATIONAL F1 RESIDENTIAL
PRINT'
CLEARLY NEW:®' RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES E] NOD;
FIXTURES 1 FLOOR—* BSM 1 2 3 4 5 8 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS1OILrSAND 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
TOILET
URINAL
''DASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER .vW
IIV URANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142, YES NO ],
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER.TYPE OF INDEMNITY BOND
OWNER'S INSURANCE WAIVER:I am aware that the licensee dues not have the insurance coverage required by Chapter 142 of the
Massachusetts General Lawns,and that my,signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER r_1 AGENT
SIGNATURE OF OWNER OR AGENT _
I her_eby certify that all of the details and infonnation 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
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Brian F,Murphy JLICENSE#19325 jON RE
MPE] aP 0 CORPORATION 0# 2'O3 PARTNERSHIPD# LLC' #
COMPANY NAME B.F.Murphy Plbg.&Htg. Inc. ADDRESS 1 72 Holten St,.
CITY Danvers ----]STATE MA ZIP 01923 TEL 9 LK 4-3174_
FAX 978-774-8TC9 CELL F EMAIL I brlan@browwnsKB.com