HomeMy WebLinkAboutP-13-707 ,-0 ,
iIlpMASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING W
CITY _ CtrMOLt+h, MA MA DATE 4 ler �!3 • PERMIT# Y 1g--�6� s
JQBSITEADDRESS J' ker." Ave_ OWNER'SNAMEI Pa*j -r •iho AS ry(is 1 i
i P OWN ER ADDRESS i Li I);rxmood ed (anon, /m [flail TEL 78%'• f-) .)'7S FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL Q'
PRINT
CLEARLY NEW: RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 I 12 13 14
BATHTUB r r r r (�
i
CROSSDICTED CONNECTIONCDEVICEAI� - r i
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM __s�� m�mi�nts�� !_mi
DEDICATED GREASE SYSTEM _; _111111111.1111111,11.1.1.11Billiatia
DEDICATED GRAY WATER SYSTEM _Wien flfuaw�_
aill
DEDICATED WATER RECYCLE SYSTEM st nns ntna �'��
DISHWASHER
DRINKING FOUNTAIN — a
FOOD DISPOSER
FLOOR/AREA DRAIN
j I
INTERCEPTOR(INTERIOR) ,, mI
KITCHEN SINK MI 1111•MIMI NS 111111111111111 MEN PIM NEM Mil '
LAVATORY 111111f '==11111.1111M1111101111111111f= SIM
ROOF DRAIN . 1111111.1111111111111111101111tapum1111111111 MIN
SHOWER STALL 1115111111111111111.1111.111111111P1111
SERVICE/MOP SINK
TOILET IIIIIIII M M M w NM.Mill_fl 111111111111111111 -
URINAL =Sflflt
WASHING MACHINE CONNECTION �_�� i _'�ssaliat , -
WATER HEATER ALL TYPES � � _'�' '�
WATER PIPING s,s^_ NI_____ a
OTHER I 111,111 1111� sa u s
i 1• j 1 i
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ :NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND ❑
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 accurate to the best of my knowle
and that all plumbing work and installations performed under the permit Issued for this application will be in compliance with all.Pertinent provision of thr
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAMErM I cMcir` Maw(' LICENSE# c9/a JLf SIGNATURE
MPD JP 9"1
. CORPORATION 04 PARTNERSHIP❑# LLC D#C
COMPANY NAME t3'U gar P/cunh ADDRESS 'I}Ct4 6/001-11 i(
CITY hi(`fYnl)G(.fln STATE /n4 ZIP Ont.17
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