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HomeMy WebLinkAboutP-17-079 ciM :1� MASSACHUSETTS UNIFORM APPLICATION TION FOR A PERMIT OPERFORM PLUMBING WORK • ;— `�r CITY 7I/// If V i)1/, MA DATE ,r6 PERMIT# WP i7��9 JOBSITEADDRESS/R D /�4% �OR H� OWNER'S NAME P OWNER ADDRESS / TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL L.f/ PRINT / CLEARLY NEW:0 RENOVATION:r REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO m 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 1 DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM _ DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN , INTERCEPTOR(INTERIOR) KITCHEN SINK / LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION / I WATER HEATER ALL TYPES / WATER PIPING OTHERRAthe ply oa r122A. 9r7s eg- c ! 1 j 1 1 ff! T{22A• fttIc Cou, INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES KNO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABIUTY INSURANCE POLICY 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 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 accur to the best of my knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be In compfa t Pertinent provision of the Massachusetts State Plumbing Code andndCha ter ter 142 of the General Laws. Q �) -1- / , /J PLUMBS 'S NAME ' 3/' y f/•�� LICENSE##t"//(/ 0 SIGNATURE MP Z JP 0 / CORPORATION #/ / PARTNERSHIP❑.# LLC S# "��G COMPANY NAME d'0�y "10€690,41 o€690,4 pt t ADDRESS �l7 , 17,60 owe' 14 �J CITY (L4`. V��l1/o�64' STATE X146 zip p th'l E C'TET9 Of�!X FAX CELL EMAIL JUL 08 2015 J • BBUICE DEPART LQ� 4. SaION MaiAl2I WY'] #1110I3d $ :33d 0 ❑ 11Wa3d 3H1SV S3A213S NOI1VOIlddV SUB. ', ISO/ 0/ / e'nIO f' 'J'� °N seA �J/rr�� Wen VO 97d ���G� Sa1ON NOI.LOddSNI`IVNId AINO aS[I aDI3301101 M012{fl St.LON NOI.L7flaSNI ONIflN[11d HOIIOH