HomeMy WebLinkAboutP-14-450 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY 1/4.Cm6j')'. MA. DATE I --3i -S PERMIT# yiy—ysv
JOBSITE ADDRESS SPAtel c r-. D p OWNER'S NAME 3-1(1-1 'A v SAT
p OWNERADDRESSI1 SCA 'ecL iJ R TECcuB')7lG -3 tSo FAX
TYRE OR OCCUP.ANCYTYPE COMMERCIAL ID EDUCATIONAL ❑ RESIDENTIAL'
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CLEARLY NEIN: RENOVATION:0 REPLACEMENT:S. PLANS SUBMITTED: YES 0 NO 0
FIXTURES 7 FLOOR I BS1JT I t 12 13 l 4 5 l 6 7 B 9 I 10 I 11 12 I 13 I 14
BATHTUB
CROSS CONNECTION DEVICE I
DEDICATED SPECIAL WASTE SYS I
DEDICATED GAS/OIL/SAND SYS
DEDICATED GREASESYS I I
DEDICATD GRAY WATER 5Y5
DEDICATED WATER RECYCLE SYS 1 I
DRINKING FOUNTAIN I
DISHWASHER
FOOD DISPOSER I
FLOOR/AREA DRAIN I I
INTERCEPTOR(INTEPJOR) I
KITCHEN SINK I I
LAVATORY I I
ROOF DRAIN-
SHOWER STALL I I
SERVICE/MOP SINK • I I I I I I
TOILET I I I I I I I
URINAL
WASHING MACHINE CONNECTION I I I
WATER HEATM Er ALL TYPES - 7 1 I I I
WATER PIPING I >c4 I I I I I I
OTHER I II I I I I I
I -I I I I I I_ 1 J
• INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which,meats the requirements of MGL Ch.142. Yes,*No❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY IOTHER TYPE OF INDEMNITY ❑ 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 wll be in
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of theGeneralLaws.
PLUMBER NAME 6-°a art Ce.)k. • SIGNATURE Gam '
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LIC# a 6 /4 MP❑ JP s CORPORATION ❑# PARTNERSHIP ❑# LLC%# D /S A
COMPA``NY,NAME Crea ti SG ?Lfl1R/,Y(r Seme itADDRESS: `li Spt'n3cr LAr
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CITY • YACm+,-`i1•n STATE MO zip 01n BAAL'
TELCSOB ) »$- 1(13 ( CFJ1SsoB )»$- /y3Y
RECEIVED
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