HomeMy WebLinkAboutP-14-404 h•>' ,.MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY (IV V-001. , MA. DATE -05 >013 PERMIT,, IN-y6'J
JOBSITE ADDRESS 1 V Ern er.(10' tia, i I-.... OWNERS NAME 1-c,yye., alae_ ' 1
P • OWNER ADDRESS: TEL: 60 z5v 4 FAX: . _. .. j
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TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIALI]C/.
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CLEARLY NEW:0 ' RENOVATION:0 REPLACEMENT:0./ PLANS SUBMITTED: YES 0 NO ai-
, t : FIXUTRES1 ' FLOORS-+ ^. Esmt 1t I 2 i3` 4...i" 5 • I"6'' '7 ''-'& 9,-, 41011 12 - 13F 14 ,Vl.k
CROSS CONN DEVICE I
DEDICATED SPECIAL WASTE SYS
DEDICATED GAS/OIUSAND SYS
DEDICATED GREASE SYSTEM I f
DEDICATED GRAY WATER SYS
DEDICATED WATER REUSE SYS I I I I I
DISHWASHER I I I I I
DRINKING FOUNTAIN I I I I
FOOD WASTE GRINDER UNIT I I
FLOOR/AREA DRAIN I
INTERCEPTOR INTERIORI ( I / I
KITCHEN SINK I (r / ILAVATORY I
ROOF DRAIN I DRAIN I I \_ I
SHOWER STALL II
SERVICE/MOP SINK I I I I I
TOILET I I
URINAL I I
WASHING MACHINE CONNECTION I I I I
WATER HEATER ALL TYPES X
WATER PIPING I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES G 1. G.
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If you have checked YES,please indicate the type of coverageveagby checking the appropriate box below. D l @ !r] C) l q
LIABILITY INSURANCE POLICY L^� OTHER TYPE INDEMNITY 0 ND ❑ •, 7;,)3
OWNERS INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required . Chapter 142 of the
'Massachusetts General Laws,and that my signature on this permit application waives this requirement. RlS'LC" '1
CHECK ONE ONLY: OWNE' ■ AGENT Q 70 WSIGNATURE 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
Knowledge and that all plumbing work and installations performed under the permit issued for this a 'cation will be in corn r n wi' all ertinent
provision of the Massachusetts State PlumbingbCode and Chapter 142 of the General Laws.
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PLUMBER NAME: '41 Thal a''r LICENSE# 1 CA n SIGNATURE
COMPANY NAME: kw.v1S . ADDRESS: CC Lir.. '
CITY: TJp,oichts l'nr1Ls . STATE: Inv*I ZIP: Qa( LS FAX: _ . __
TEL: 608 ,n1--:?_35-1 CELL: EMAIL: 1
MASTER IR" JOURNEYMAN 0 CORPORATION 0 41 PARTNERSHIP RI. • LLC 0# /�/�
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