HomeMy WebLinkAboutP-19-1475 I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
==e- ° CITY MA DATE PERMIT#44N)-/9-OO/94'
JOBSITE ADDRESS 13 C 71,07 1'lgl4 f Ai ev OWNER'S NAME Ke;re......,-
P OWNER ADDRESS S G Yt'1 e-
,5 tolifte 'TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 22,
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
FIXTURES 1 FLOOR-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM '"
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER --- - ID
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY r • EP icin ccal
ROOF DRAIN
c �rr,:S i!;• �
I SHOWER STALL - • ._,js "_
I SERVICE/MOP SINK •
I TOILET f
URINAL
. WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING _ '
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Ly NO 0
IF YOU CHECKED YES,PLEASE INDICATETH E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY (K OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
1 Massachusetts General Laws,and that my signature on this permit ap?lication waives this requirement
st CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
I-I 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 co fiance tvith all Psion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C
PLUMBER'S NAME _ �IJCENSE# 13 a I Q r SIGNATURE
MP[bJ JP 0 c� CORPORATION lf1# PARTNERSHIP❑.# LLC 0#
COMPANY NAME -1 LckeJ)r ? (tom Lid l& !i ADDRESS 97 if 11J0u° a-,Acr not
CITY Kir In 0 Ott STATE M 41 ZIP O 2 6 10 4 TEL Cat -23 71(41/
FAX CELL c0 - EMAIL j p
t
frve110