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HomeMy WebLinkAboutP-19-957 MAP : PRA eel MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORKiliZT CITY YAQtAOOSO" T — I MA DATE IL, J PERMIT#�IO /?-0OoT lil_ ' 4 JOBSITE ADDRESS 140n r;n r31 Ln . 1 OWNER'S NAME Pal,l A r4 nV r P OWNER ADDRESS ! TEL 617 golf 14?S FAX TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL El RESIDENTIAL PRINT CLEARLY NEW❑ RENOVATION:❑ REPLACEMENT:v PLANS SUBMITTED: YES❑ Nap • FIXTURES Z FLOOR- BSM . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUBV ,I r I I CROSS CONNECTION DEVICE S' flf=�SS_ DEDICATED SPECIAL WASTE SYSTEM �n nausamumit DEDICATED GASIOIUSAND SYSTEM a;� MI M NIS�aM'MIR PM IS DEDICATED GREASE SYSTEM DEDICATED G' YWATER$YSTEMMa'IS I DEDICATED WATER RECYCLE SYSTEM MEI! S _ DISHWASHER- �� MaMa '�rarM DRINKING FOUNTAIN on Wi_ a a a'.aiai�i.a a lim,mi PM AM INTERCEPTum FLOOR/ OR(INTERIOR 2 II WSW 5,5 w.a s P a MI NW 5i l FOOD INNISIVIWWW P li LAVATORY I .I -71-.."-“0- Mill usa�S�� 55a—. KITCHEN SINK- �; c_. flfl ROSHOF RAIN __'____ r s `l f f 5lf. lfi'. IIt;( � . ROOF DRAIN' I ��_,�� ��al��� Mt MIMI PIM MI 11111111,11111111 int MI MIR SERVICE MOP ( :Maiinga_S PIM MIWEMI:S_MI TOILET Mit elli.1.11 1.111ME MI=Ma URINAL MM--MIMOMIWi5—S—S MIR NM WASHING MACHINE CONNECTION inirmillsinsruniriiininsimiSiSS WATER HEATER ALL TYPES ttff a me MI 1.11 WSW 1.111111kam els a -re iirmt ms ark ma mil limn ma pm Fa maw !Sr JSTfb_1aT.►Waa,ii�a _MIK MI UMW 5111.11M111.111.1111... TIMOMMIl ma SS ma Mr MN NIS pa pa rim .nomwig Soma at Pimas a'no Ns sla INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 2/NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY U".! OTHER TYPE OF INDEMNITY© BOND OWNER'S INSURANCE WAVER: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 aU 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=ma/lance math on of the G�k Massachusetts State Plumbing Code and Chapter 142 of the General Laws. J PLUMBER'S NAME 14/Pll:r GIl c,.8r;cJ?. !LICENSE# i It9o'O SIGNATURE MP Ei JP❑ n/ CORPORATION#0226k C. 'PARTNERSHIP❑# LLC❑# COMPANY NAME AAA A4 A;cif P4 N. =i1r , IADDRESS II £OCA $4 f n I 1 CrrY W. %.e-n.ov4A STATE MU ZIP 02.g'3 TEL (60E) 455E ) FAX 4of-in o.nfrn CELLLs0)3t4•37 EMAIL r,Riomb 19 romras4 me,-I r . fr-- 0 07( k 7/,