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HomeMy WebLinkAboutP-18-4974 ' . &. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK - I IB=c� • _ CITY . yA,,Mott f4porgy (` MA DATE) 3 /747 (PERIvima, #'/Y-04937Y( JOBSITEADDRESS '/0 G)rr/4crfc 44.4w 1OWNER'SNAME ire-Viv froYC•c S OWNEZADDRESS j49 le- I TEI.I tg"-lex— p(FAK -- • . TYPE OR OCCUPANCYTYPE COMMERCIAL® - EDUCATIONAL ED • RESIDENTIALE . PRiNT CLEARLY NEW:® - REMOVA1TOfr REPLACEMENT:© :PLANS SUBMI TED:YES El No- • FIXTURES 1 FLOOR-I• - BSM 1 ©© 4 5 0m0 9 10 11 12 13 in BATHTUB ' • I @6AI{tll° n8inlil . CROSS CONNECTION DEVICE _ II . $11.111111. I ° P ._ I _ _ a DEDICATED SPECIAL:WASTE SYSTEM ISIMISi66 D DEDICATED GASIOIUSAND SYSTEM SiMt on" inISspon ' DEDICATED GREASE SYSTEM 11-7111111.11 r _ _F-� �+�Jamilli DEDICATED GRAY WATER SYSTEM 1 ----- � oiaI . DEDICATED WATER RECYCIE SYSTEM - A�M1 ) E______ �J����___ DISHWASHER • train iJnil J t allinla DRIN, NG FOUNTAIN ..___.'.flkp1f _ 111.@___ 6 6 4 + - FOOD DISPOSER -- C _ _A agisii11�tfl : _ sacs FLOOR/AREA DRAIN LMEII E [ an t �Milar. INTERCEPTOR(INTERIOR n6illiI MISMIIIRIPIIII6�� ____ 6.1111 a e Ip[61 X8 +. 9 6 #111s1 91 lgi .i • ROOF DRAIN sii.analillainnal SHOWER STALL j4 ( 1I __ 6 1 SERVICE I MOP SINK �ii1.111i lllallial i cilli . p TOILET aagi iSial.1 «J _ � I WASHING MACHINE CONNECTION niminstimple_u71��6�; laualSOMMLIMasitiillminnaiiiiinnut OTHER W J. ra i ._ 6f baaat1 - ._,__ -1 3 11 1.1.I 9sEa "Rye L Li INSURANCE COVERAGE: 3 I have a cunrentlability insurance policy br Rs substantial equivalentwhich maee the requvements of MGL Ch.142. YES NO 0 pAR 11i IFYOU CHECI�DYESPLEASE INDICATE THE TYPE OFCOVERAGE BYCHECKING THE APPROPRIATE BOX BEL019 1 �f/ N-g7A IJABMYINSURANCE POLI r-7�� - r_ ytr ���SSS POLICY OTHERTYPE OFINDEMidkTY[� BOND 0 ,'.,JI_L,N<;!)EPAFt MENT OWNER'S INSURANCE WAIVE%I am aware that the licensee does not have the insurance coverage required by Chapter'42 of ttt .Massachusetts General Laws,and that my signature on this permit application waives this requirement • CHECK ONE ONLY: OWNER Q AGENT 0 SIGNATURE OF OWNER OR AGENT • I hereby certify that ad of the details and information I have submitted or entered iegmtlmg this application are true and accurate to the best of my knowledge end that aft plumbing wodc and Installations performed under Bre permit Issued(alibis application will be in to p11ante with all Pertinent provision of the Massachusetts Slats Plumbing Code and Chaplin 142 of the General Laws a-•• - e PLUMBER'S NAME /'PA./P�i �` a(r;4EGDRib t�'r: ILICENSE g 9_r3 • sic RE' • • . MPir JP[( • CORPORATION(SI# 3 Gig(YIPARTNERSHIPQ# ILO • . • - COMPANY NAME .7 GJ-. cad/ - • .--• )LI ADDRESS ler, 7f`/L2fur ii- r to.T"tie ! I � CITY i1�� 0Cr-7' (stATE�J ZIP 0.24:79 ' 1 TQ- .StTar-3Qa ppv ! y FAX rillirliffiM CELL EMAIL La .t2_• //w_._i • • - I SNS piykdamr.•Whnp Itkmmaaryto ma..aatat=ta rooaiaaduwash=, this m.4 mtab=the bapmm. smsmabla istgeta bepme .-•tutor= um utmapaa4w cantata 't Is mmarym at 0tiltsedit at evkil±a oWmuce nartatst®rgiymmarFaclar.,Mat+reark— trd to e®rumnsaacearpmatteaomhh t.kep¢xmmpafetat Men ivpem8 bvthkct. pMilted I t finch stuarganalcobaamgiddotapdsathkbepmmdedtashsa.marmpsmed If=I ncn.mpalamk Isetoviad.!M>mosmah irmemain=at faertm=to thema=n whops=baying theta armstmidthasm:cum orpmaimad temaaepar.atarn&S ag thearignassrdug Iwo mown in thmandne pmadd bybre taaam eVry ko F,Pkvg-c- /ok.b, dyr 2 kr 94*