HomeMy WebLinkAboutPlumbing PermitI � MASSACHUSETTS UNIPORM APPLICATION FOR A PERMIT TO PEIfFORM PLUMBING WORK
CITY S�u-�-(.� �u,rmou� pqq DATE I2'��{^Z�9fS ! pERMIT# h�P��n-�O .�"j
JOBSITE ADDRESS 3"1 Wc�Ou.n o� aeeQ OWNER'S NAME I�tl 6u�f' �J;r k..,'v�
P OWNERADDRESS TEL ��7'S'W-HI«t FAX
TYPE OR OCCUPANCY NPE COMMERCIAL❑ EDUCATIONAL ❑ RES;DENTIAL�
PRINT
CLEARLY NEW:� RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7 FLOOR-+ BSM 1 2 3 4 5 6 7 8 !9 10 17 12 13 14
�� &4THTU8
\ CROSS CONNECTION DEVICE
� DEDICATED SPECIAL WASTE SYSTEM '
� DEDICATED GASlOILISAND SYSTEM '
� DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
� DISHWASHER
DWNKING FOUNTAIN ,
FOOD DISPOSER �
k FLOOR/AREADR4IN ,
4 INTERCEPTOR INTERIOR) �
KITCHEN SINK ,
�y LAVATORY
� ROOF DRAIN
SHOWER STALL ,
� SERVICE 1 MOP SINK �
TOILET
URINAL �
� WASHING MACHINE CONNECTION �
�� WATER HEATER ALL TYPES
WATER PIPING
OTHER
S � ;
S �
INSURANCE COVERAGE: �I
I have a current liabili 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 COVER.4GE BY CHECKING THE APPROPRIAiE BOX BELOW ���a����D
LIABILITY INSURANCE POLICY � OTHER TYPE OF INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WANER:I am aware that the Iicensee does not have the insurance coverage requ by Chapter 14�oft1S�5
Massachusetts General Laws,and that my signature on this permit application waives this requirement
I IiEALTH DEPT.
CNECK ONE ONLY: OWNER AGE
SIGNATURE OF OWNER OR AGENT
I hereby certify that all oF the details and InformaUon I have submitted or eMered regarding this appliptlon are true a d accurete to ihe best of my knowledge
and thet ali plumbing work and installations perfortned under the permR issued for this appiicatlon will be in complian e wtth.a er6nent provision of the
Massachusetts State Plumbi�Code and Chapter 142 of the Generel Laws. �
PLUMBER'SNAME S�� I-Ean�r,��a... LICENSE# �I�r33 SIGNATURE
�P❑ �P� CORPORATION�# PARTNERSHIP 0# LLC❑#
COMPANY NAME S�'� I-i�inr�(n� � r-�-{ ApDRESS �d �J K (o ��'
CITY �n����� STATE M�— ZIP �ZCo 3 2 ITEL ��'f�&'-0 2�(,
FAx ��s—�t�is CELL EnAai�_ s�r��spl��6� 5G y�yio., _ c��,._,
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