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HomeMy WebLinkAboutP-12-499 t'_ MASSACHUSETTS UNIFORM APPLICATION = w FORA PERMIT TO PERFORM PLUMBING WORK CITYriii CITYJOBSITEAOOREgg • MA. DATE PERMIT,.112-z _SIL. P OWNER ADDRESS PER'S NAME air w TYP&OR OCCUPANCY TYPE TEL��FT-�� PRINT COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIA�t CLEARLY NEW 0 RENOVATIOM 0 REP T f� FIXUTRE31 f� PLANS SUBMITTED: YES❑ NO 0 1102aummell Mil Mal FLOORS—. Bair o©© 4 S 8 v 8 9 10 11 12 _® 14 DEDICATED �WASTE SYS _____�__CROSS CONN DEVICE lel �______ DED111111111111111 ICATEDGREASE SYSTEM SAND SS ___���_ ___��� DEDICATED GRAY WATERSY9 _ ��_�_ DEDICATED WATER REUSESYS ��___ — ee Mee Neel le DISHWASHER elan le 111111 DRINKNpFOUNTAIN _________ _____ FLOORVJAREADRAIGRINDER UNR _____IIIIIIIIIIIIIIII _____ KITCHEN SINK le le le elle le INTERCEPTORINTERIOR __________ ___ IIMIIIIII Me LAVATORY DRAlti Fl�l lel la ____—_0__ _ SERVICE/MOP SINK IIIIIIIIIII_ ________el eel Miller SHOWER STALL Mil MIN an 111110 IIIne __ TOILET el Mee le lel WATERHEATERIAU.TYPEES __CTION le le le el �_____ WATER PIPING �1♦_S�7=�_________ Q__r� �rrac ����� �i Ihaweraeratyj( a policy altssubsnrtdalINSURANCEC COVERAIle annimine GE I have you have,rent gad equivalent wadi meets the of MGL Ch.142 .:31,V r 11 its please Indicate the type of coverage by cheating the appropriate box below. V D LIABIUfY INSURANCE POUCY �" OTHER TYPE mean. 0 BOND Ie MAR/ OWNER'S INSURANCE WAIVER:I am aware that 8N licensee de 4awance 19 2012 M�sadersetb General Laws,and that my signature on this penal a coverage required by . 14 ., ., PPdatlarl] dfbrequlrtyttwk BU L� G �E'A' �� NT • 8Y: _ SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0 IK hereby a rifd that al dudetab and watt and Information I have submitted(or entered) this l'POatbn am true and accurate to 8N beet of my h+mnatlaq perbrmed under the application wall be In provision ci the Massachusetts State Plumbing Code and Chapter 142 of Ow Genial Laws, �"D a Wer al Perfherd PLUMBER NAME ranigraza �"� LICENSE r© SIGNATURE COMPANY NAME sienralMtaim ADDRESS IMirariMmairamml CITY: /j STATE:, TEL ZIP: 0 a FAX ` CELL:=Mai EMAIL SER El JOURNEYMAN 0 CORPORATION Os PARTNERSHIP 0 r oLLGCIrO ._—---..mwd —_ ' WifinrMICIMIIM ______---C------- on seA � /W. r