HomeMy WebLinkAboutP-13-826 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY MOw� MA. DATE S/3�/!3 PERMIT#1'G1,3` f�(oJOBSITESS (I4 CdrPkA., LJr,J4I Rd OWNER'S NAME
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pOWNER ADDRESS SAr"'1 r TEL Snr go-6,05%
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 /EDUCATIONAL 0 RESIDENTIAL E�
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CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:E1 PLANS SUBMITTED: YES ElNO 0
FIXTURES 7 FLOOR-» BSMT 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYS
DEDICATED GAS/OIL/SAND SYS
DEDICATED GREASE SYS
DEDICATD GRAY WATER SYS
DEDICATED WATER RECYCLE SYS �
DRINKING FOUNTAINS: CD 6 ((4 Id - \i (- '1
DISHWASHER
FOOD DISPOSER
FLOOR/AREA DRAIN MAY 3 I 7013 0
INTERCEPTOR(INTERIOR) _
KITCHEN SINK Gii.Jrv.o�cr'1
LAVATORY:-.:.
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK
TOILET
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 0 No 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Er 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 Pertinentfprovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.�
PLUMBER NAME I)'<<Chal,( Lee CZ SIGNATURE ;:are9 0/1 V
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LIC#Ia/5?— p MP BJP❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME Lo re-a P(w" la titla ADDRESS: 'D lis A 44,1 57-
CITY=. Br: JyzifratkrSTATE .1114 ZIP Ol 733 EMAIL
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