HomeMy WebLinkAbout2014 Jun 03 - Plumbing Permit - Water Heater T
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� MASSACHUSETTS UNIFORM APPLICATION�OR A PERMI7 70 PERFORM PLUMBIiVG WORK
CITY O lC�" ! MA DATE PEf2NlIT# � `7�b
J08SlTE AQDRESS ��it/_l1 l�+1�+�rz- L/k�U r% OWNER'S NAME�f�Lb �J� �G�
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P OWNER AODRESS �X�,�G�`�, ����/ TEL d�'�D -�� � FAX '
TYPE OR OCCUPANCY TYPE COMMERCIAI.❑ EDUCATlONA�. ❑ RESIDENTIAL[�
PRINT
CLEARI.Y NEW:❑ RENOVATION:❑ R�PtACEMENi':[� PLANS SUBMITTED: YES❑ NO❑
FfXTURES Z FLOOR—+ BSiN 1 2 3 4 5 6 7 8 9 10 t9 i2 t3 14
BATHTUB
CROSS CONNECTEON DEVICE
DEDICATED SPECIAL WASTE SYSTEM ,
DERICATED GASlOIUSAND SYSTEM '
DEDICATED GREASE SYSTEh{
DEDICATE�GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DfSNWASHER
DRINKiNG FOUNTAfiV '
FOOD DfSPOSER
FLOOR/AREA DItAIN
d�lTERCEPTOR(INTERIOR
KlTCHEN SINK '
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVECE/MOA SlNK
TOILET
URINAL '
WASHING lNACHINE CONNECTION '
.. ?ER At�"�YPF_�.�.. .
�VU�'�E �IF?EI�G �
'QTWER _
INSURANCE COVERAGE:
!haue a c�rrent '�bi' i�sura�c�:policy or its substantial equivalent which meets the requirements of MGL Ch,142. YES❑ NO �
If YOU CNECKED YES,PLEASE IhlDlCATE T1lE TYPE OF COUERAGE BY CH�CKING TNE APFROPRIATE BOX BELOW
LIA8ILITY IiJSURANCE POLICY ❑ OTHER TYPE OF INDEMNITY ❑ BONt� ❑
OWNER`S INStJRANCE WAIVER:I am aware that the ficensee does not have the insurance caverage required by Chapter i42 of the
Mass setts G eral s,and that my signature on this permit application waives this requirement.
I CHECK ONE ONLY: OWNER �GEN7 ❑
i SIGNATURE OF OWNER OR AGENT
I hereby certify fhat all of the details and in(ormation I have submitied or entered regarding Ihis applicailon are We a»d accuraie to tiie be my knowledge
and ihat afl plumbing work and lnsiaflattons performed urtder the permit fssued tor lhis applicaUon wiil be in comp tin al Periin rovisian of Ihe
Massachusetts 5tate Plumbing Code and Chapter 142 of 1he Gerteral Laws.
PLUMSER'S NAM� ��N� vv��5��/�� LICENSE#�3 J �c� SIGNATUR�
' MP❑ JP�J CORPORATfON[]# PAR7NERSHIP�# LLC 0#
� COMPANY NAME I.�D/0 SL�'L tvh �-r" <f . ADDRESS y��?�Z�' � ',
� CITY�/9-'�?�f T7`� STATE_-C�"LL ZIP—_D�'��� TEL �Ol7.J��07 'G�T'
FAX CELL /�-�9L '�o�f�� EMAIL
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