HomeMy WebLinkAboutP-13-850 1/ 30 —'/P 'ICI
MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
s� CITpp
Y y0Ktv7au1rF, )202T MA DATE !e(/OI f3 PERMIT# PIS 8Sn )
6JOBSITE ADDRESS c76 tv7,4 i4 7 A�v C, 4' OWNER'S NAME .w> ern tog cc.
p OWNER ADDRESS ' Jr.w..c TEL FAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 ED CATIONAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW:0 RENOVATION:' REPLACEMENT: PLANS SUBMITTED: YES 0 NO ❑ I
•
g VA FIXTURES 1 FLOOR—. BSMT 1 2 3 1 4 1 5 8 I 7 I 8 1 9 I 10 I 11 I 12 � 13 I 14
BATHTUB I I 1 I I
CROSS CONNECTION DEVICE � I
II— DEDICATED SPECIAL WASTE SYS I I I I
V
DEDICATED GAS/OIUSANDSYS I I I
DEDICATED GREASE SYS I I I 1
DEDICATD GRAY WATER SYS
DEDICATED WATER RECYCLE SYS I I I
DRINKING FOUNTAIN I I I
DISHWASHER i I
I I
FOOD DISPOSER
FLOOR/AREA DRAIN I I I I
INTERCEPTOR(INTERIOR) I I
KITCHEN SINK I I - I I I I I _
LAVATORY 2 I • I I
ROOF DRAIN.' I I
SHOWER STALL J I I
SERVICE I MOP SINK • I I I
TOILET I I I I . I I _
URINAL I I I I I
WASHING MACHINE CONNECTION II
WATER PIPING ALL TYPES �� 3 I
WATER PIPING /
OTHER
;$;:i4er I IINSURANCE COVERAGE: EY
I have a current liability Insurance policy or its substantial equivalentwhich,meets the requirements of MGL Ch.142. Yes L`3'No 0
IF YOU CHECKED YES,PLEASE INDICATETHETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Ly OTHER TYPE OF INDEMNITY 0 BOND ❑
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 all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 1 f the .eneral Laws.
PLUMBER NAME 37>ti r1 krs K: SIGNATURE \- '/... /
UC# / 9'944 MP❑ JP❑ CORPORATION ❑# PARTNERS• '�❑# LLC ❑#
COMPANY NAME --�— 7 ADDRESS: 10 P �K t a r
CITY soteN-, STATE Si hit ZIP O357`) EMAIL' JS'so/ucPIQ C 1vlwIl . Curl
TEL Cc1�-a,3 I,/-6/./5/ CELL FAX _1 q •
I' IC 1 Iri 'i9 �.1 1 1I II
IJ
•
J- JUN 10 2015
J •
•
•
1
- I U
\n
1--------------------
V
-------- ---------. .." k
R
W L
. _
S:l.LON MaLIA Lu NV7d
iiin3d $ :33d
❑ ❑ 1111U3d 3Hl SV S3AU]S NOIIVOIlddV SII-1.1 l- I
�
oN GOA 5:7A0
l� AN/
SasON NOI.1.01dsN17VNI1 Ar1NO HSU uoJ D1dsNI 2101 aDV,d 5111.E SHIO1.LMWSNl ONlUW117d 11011011
r