HomeMy WebLinkAboutP-18-2688 ,,.-1, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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T -c>r f 'V MA DATE 1 I\ 6 111 PERM FT#"OA/9'-OOa�%5
JOBSITE ADDRESS LI S( (O Z o it A-4 L 14- OWNER'S NAME
P OWNER ADDRESS TEL FAX
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TYPE OR OCCUPANCY TYPE COMMERCIAL❑ • EDUCATIONAL 0 RESIDENTIAL 1
PRINT
CLEARLY NEW:0 RENOVATION:ch. REPLACEMENT:0 PLANS SUBMITTED: YES 0 NOC
FIXTURES 1 FLOOR-• BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB i,
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY 3
ROOF DRAIN
SHOWER STALL 1
SERVICE/MOP SINK r f
TOILET q) 1 i s t ,
URINAL I ' i —
WASHING MACHINE CONNECTION IQ11 i i
WATER HEATER ALL TYPES I 0 I( Z ` i{ \/ p
WATER PIPING �`�r1/!,,i T� E=T A
OTHER _ l
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES IA NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 4 OTHER TYPE OF INDEMNITY 0 BOND 0
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 0 AGENT 0
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 (lance al rti revision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME UCENSE#763 C IGNATURE
MPb JP 0 CORPORATION 0# PARTNERSHIP 0# LLC 0#
COMPANY NAME N4((/E PO/Pl8/tll6 #-/fr 7NC ADDRESS 6a- New ZUmcTOA' 2.0.
CITY 1(AIAR tV STATE kik ZIP Oa4 3? TEL Spk--3 SS 47S 5-
FAX
FAX CELLsag-36q-tinno EMAIL rUflhcljj(Lte'lflhe(2luti
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