HomeMy WebLinkAboutP-14-187 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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JOBSITE ADDRESS c l . #fT.4)!N f, s'aA/OWNERS NAME T�/(" Ggcp/f.
OWNER ADDRESS Sa,i. TEL Mi-99ft-WAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL EDUCATIONAL 0 RESIDENTIALZ-"
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:(' PLANS SUBMITTED: YES 0 NO a—
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FIXTURES 2 FLOOR-4 BSMTI1 2 I 3 41516 I 7 8 9 I 10 11 12 13 I 14
BATHTUB e I i
CROSS CONNECTION DEVICE I I
DEDICATED SPECIAL WASTE SYS I I I I
DEDICATED GAS/OIUSAND SYS I I
DEDICATED GREASE SYS I
DEDICATD GRAY WATER SYS I I J I
DEDICATED WATER RECYCLE SYS I
DRINKING FOUNTAIN I
DISHWASHER a - rV _ I,
FOOD DISPOSER
FLOOR IAREA DRAIN I I
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INTERCEPTOR(INTERIOR) I I 1 Lf 1 I,
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ROOFER ' Tei -__=-40.
SHHOWER STALL I I
SERVICE/MOP SINK • I I I I I I I
TOILET I I I I I 1
URINAL I I I I I I i I _
WASHING MP.CHINECONNECTION I I I I I
WATER HEATER ALL TYPES
WATER PIPING _
OTHER I I I I I -
1 I I I I I 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 TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Ere. 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 BOX ONLY: OWNER 0 AGENT 0 •
Signature of Owner or Owner's 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
compliance with all Pertinent provision of the Massachusetts/ State Plumbing Code and Ch,pte 2 of
the G eral Laws.
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PLUMBER NAME Zia - i�D//f�011T�fi. SIGNATURE ‘ L`
UC# 4 VW 1 MP❑ JP L/J CORPORATION El#
PARTNERSHIP ❑# LLC ❑#
COMPANY NAME Ad/4r Sg 4Jf0p ADDRESS: /o' a'AY tirna 7 Za.
CITY CZ' ,e.ime971 STATE vee zIP eSiy EI#JL
TEL Stir -g" ;579.a CELL Sy f FAX_5 S9/-o/ •
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