HomeMy WebLinkAboutP-13-514 2: ,, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
• r=: MA DATELW/7 13!PERMITs /3—S/ if
L= " CITYLya fie- — l P
"SIM ADDRESS L/9 , 'ee c i 6.1 j oWNER'S NAME[Mwi12 6v416.0 f I
P OWNERADDRESS 3 (1By_VlevroM,.✓aiz {{ I Tar FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIO NN_ ❑ RESIDENT
PRINT
CLEARLY NEW:❑ RENOVATIOIt❑ REPLACSeOT:' ! FLANSSUBMR7ED: YES❑ NO
FIXTURES 7 FLOOR-• oa 1 2 3 4 5 5 7 8 9 10 11 12 13 14
BATHTUB -
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OR/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM
DISHWASHER -
DRINKING FOUNTNN
FOOD DISPOSER _
FLOOR IAREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY _ _ _. _ - -
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK
TOILET - _
URINAL
WASHING MACHINE CONNECTION _ _
WATER HEATER ALL TYPES
WATER PIPING
OTHER i _
INSURANCE COVERAGE
Ihave acrrertliabilityinstancepolicyadssui�tialtpavalent which s the of�CIL 142. YES a No ci
W YOU CHECKED YES,PLEASE IOICATETIETYPE or COVERAGE BY CHECKINGTHE APPROPRIATE BOX BELOW
LIABIUTYINSURANCE PCUCY E OTTER TYPE OF INDEMNITY❑ BOND U
OWNER'S INSURANCE wAIVEIt I am sae 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 ONLY: OWNER El AGENT ri
SIGNATURE OF OWNER OR AGENT
I hereby certify that at of the details and timneeon I have submitted orente ed mgardrg this application are hue and accurate b of my knowledge
and Mal al plumbing mat and i siala8as perfumed ander the penia issued fort is app_ratuon call be in oanplace . all Ptorision of the
Massacimele State Plumbing Code ad Chapter 142 of the General laws- _
PLUMBER'S NAME 1 R Peter Chedroway LICENSE#f 73417. TIRE
MP JP CORPORATION)# PARTNERSHIP C# LI.CEfti I
COMPANY NAME;dtedcoway enterprises ADDRESS 11 scafgo full rd
CETY�i fiiefuus STATE ma ZIP 02638 j TE-I508.385-19h1
FAX 508-385-6858 - CELL 508-735-9993 IEMAB. checkonf@comcastnet _.�_�_ _n_nn_{2 U l
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