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HomeMy WebLinkAboutP-13-687 [""SC • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ejCIN S y,4�.,r1oUt 4 MA. DATE //"//3 //PERMIT# 91 6637 JOBSITEADDRESS /2./ X/vitt 57 OWNER'S NAME Ka7C G2).-4.6 e pOWNER ADDRESS TEL FAX , �^ l TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL LT PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:[�' PLANS SUBMITTED: YES 0 NO • FIXTURES 1 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 FOUNTAIN DISHWASHER FOOD DISPOSER FLOOR/AREA DRAIN KITCHEN SIOR(INTERIOR) ttnitp LAVATORY �l ROOF DRAIN SHOWER STALL SERVICE/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 1 11 ❑ IF YOU CHECKED YES,PLEASE INDICATE !3jF-TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [vj 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 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 allPertinentprovision/of the Massachusetts State Plumbing Code and Chapter 14 of General Laws. PLUMBER NAME /312-IIJP/}NL/� I b&A.,r SIGNATURE LIC# !/f 7 7 MPS ❑ CORPORATION [l# PARTNERSHIP ❑# LLC ❑# COMPANY NAME Ctsr/dc C, A /N( ADDRESS: if D , /S a,? 9 Z CITY 5 1)deify/ I STATE ZIP 42-le 0 EMAIL TEL,SblP' -35P - 2LZP CELL 1 IK f r fl nr P c . 11 APR 11 2013 &9� • I ROUGH PLUMBING INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 0 FEE: $ PERMIT It PLAN REVIEW NOTES 1 r� V