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TYPE OR
PRINT
CLEARLY
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY MA DATE PERMIT # ______________________
JOBSITE ADDRESS OWNER’S NAME
OWNER ADDRESS TEL FAX
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO
FIXTURES
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/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
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE / MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
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 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 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
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
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
____________________________________________
PLUMBER’S NAME LICENSE # SIGNATURE
MP JP CORPORATION # PARTNERSHIP # LLC #
COMPANY NAME ADDRESS
CITY STATE ZIP TEL
FAX CELL EMAIL
BELOW FOR OFFICE USE ONLY
Yes No
THIS APPLICATION SERVES AS THE PERMIT
FEE: $________________ PERMIT # ___________________
PLAN REVIEW NOTES
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FINAL INSPECTION NOTES
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