HomeMy WebLinkAboutP-13-783 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK i
CITY rAZ KO"rot- MA DATE 1/4,57/f 3 PERMIT# Pis— W3
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JOBSITE ADDRESS /IrcrerEVA C X OWNERS NAME Teti Rf/laa/
OWNER ADDRESS icer ICe S-Tet, INA_ 'fC IreenviTEL FAX ������
MP TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
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CLEARLY NEW:0 • RENOVATION: REPLACEMENT:0 PLANS SUBMITTED: YES 0
NO 0
FIXTURES 1 FLOOR-' I BSMT 11 I 2 I 3 4 5 6 1 7 18 9 I 10 11 12 I 13 14
BATHTUB I / I 1
// CROSS CONNECTIONDEVICEI
DEDICATED SPECIAL WASTE SYS4
DEDICATED GAS/OIUSAND SYS
DEDICATED GREASE SYS 1
DEDICATD GRAY WATER SYS I _
DEDICATED WATER RECYCLE SYS I _
DRINKING FOUNTAIN I ,
DISHWASHER I / 1
FOOD DISPOSER I I
FLOOR/AREA DRAIN 1
INTERCEPTOR(INTERIOR) 1 I
KITCHEN SINK / { I
LAVATORY.. -. / / • .1 1
ROOF DRAIN
SHOWER STALL
SERVICE IMOP SINK • / I I 1
TOILET / . / 1 • I 1 1
URINAL . I I
WASHING MACHINE CONNECTION / I
WATER HEATER ALL TYPES ,
WATER PIPING / -
OTHER • I I I
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INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which,meets the requirements of MGL Ch.142. Yes/IN No❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY 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
1 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 Chapter 142 of the eneral Laws.
PLUMBER NAME LJP. ctC a. Ld✓ KU SIGNATURE ,,,,t..4
LIC# 7 C6 S MP ck JP❑ CORPORATION ❑# PARTNERSHIP ❑4 LLC ❑#
COMPANY NAME to R c.T c t t—O 1 o ADDRESS: /' Tr 0 L 3e CoC,07V1"629
CITY ?Li fi4by'c STATE/A/1- ZIP a„.i(A,-e/ EMAIL
TEL 5'03- 7 7 G 73 97 CELL 5 Ot 7 7‘ c137% FAY
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