HomeMy WebLinkAboutP-14-444 ' MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
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T� 2 SrPSRE ADDRESS Carol ✓V1 OWNER'S NAME c)O t C/NGLV4'
OWNER ADDRESS TEL FAX
TYPLEOR OCCUPANCY TYPE COIJIJERCIAL❑ EDUCATIONAL RESIDB1TIALg----------
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CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED:i ED: YES 0 NO 0
FIXTURES 1 FLOOR-' I BSIJ,T 11 12 3 I 4 I 5 3 I 7 I 3 I 9 I 10 I 11 I 12 13 14
BATHTUB I I I I I
CROSS CONNECTION DEVICE I
DEDICATED SPECIALWASTE SYS I I I I
DEDICATED GASIOILISAND SYS I I I I I
DEDICATE)GREASE SYS I I I I I
DEDICATD GRAY WATER SYS I I I I
DEDICATED WATER RECYCLE SYS I I I I
DRINKING FOUNTAIN
DISHWASHER I I I I I
FOOD DISPOSER I I I I I
FLOOR/AREA DRAIN I I I I I I
INERCEP I UR(INTERIOR) I I I I I I
KITCHEN SINK I I I I I I
LAVATORY=-. I I I - I I I
ROOF DRAIN— I I I I I
SHOWER STALL
I I I I I I
SEERVICE/MOP SINK • I r I I I I
TOILET I I I I ' II
URINAL
I WASHING MACHINE CONNECTION I I I I I I
WATE2.HEAra ALL TYPES I I I I I I I
WATER PPWG I I I I I I
OTHER I
i I I I I I
I IJill I_
INSURANCE COVERAGE:
I have a currant liability insurance policy or its substantial equivalentwhich,meets the requirements of MGL Ch 142. YesNo❑
IF YOU CHECKED YES, PLEASE INDICATE THE E OF COVERAGE BY CHECKING THE APPROPRIATE BOKBELOW
LIABILITY INSURANCE POLICY OThER UP!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 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 appli.c;..r:are true and accurate to the
best of my Knowledge and that all plumbing work and installations performed under the permit '--us. for this application will be In
compliance withal nent provision of the Massachusetts State Plumbing Code and Chapter of th- General jaws.
PLUMBER NAME CO/ ( `J L?'�'�//V ict SIGNATURE /
L If;7/ St/ leo JPIg----CO RATION Off /PARTNERSHIP/❑S LLC ❑$
COMPANY/NAME ( 7G✓et/nt✓ p/H ADDRFSS: "1 5- ( 7C0SS"M 4571-
Girt
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Girt l 1 u)Mr( STATE. ZIP dO1 1�� EMAII.
TEL 6/7 7(O 700 / CELL R E C E tIV D
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EC272013
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