HomeMy WebLinkAboutP-13-466 . 'C
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT To PERFORM PLUMBING WORK
CITY 4's/rigLGIOtf/l BsItf x MA. DATE / /G-�> PER�MIIT# /Ply 966
JOBSITEADDRESS_i3o, t/%I/G)4 '5't OWNER'S NAME /a/4e (_2Ugel icy
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIALM
PRINT
CLEARLY NEW:0 RENOVATION: - REPLACEMENT:® PLANS SUBMITTED: YES❑ NO g_
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 GASt01USAND SYS
DEDICATED GREASE SYS
DEDICATD GRAY WATER SYS
DEDICATED WATER RECYCLE SYS
DRINKING FOUNTAIN
DISHWASHER
FOOD DISPOSER ,I 1
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN
LAVATORY SINK
a V 22 2013 ily
ROOF DRAIN BU�2Dtwn
SHOWER STALL y f�
SERVICE I 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 No 0
IF YOU CHECKED YES,PLEASE INDICATE T TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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 Owners 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 is ap licatlon will be In
compliance with a( � r/ -Car--Car-AS 1-16-ll� La
Pertinent provision of the Massachusetts State Plumbing Code and Cha er 14 • - e i- . j L
PLUMBER NAME ND iSIGNATUREii
UC# //24914 MP 111./JP❑ CORPP RAT N ❑# PARTNERSHIP ❑# LLC O#
COMPANY NAME 77/2--1-1- P r� ✓J /ADDRESS: 2 D Mit/1 y r7 LC7
CITY Yryy✓SJ-Qr �jSTTAATE� L�EMAIL
TEL S� 7, a 9Z% 3 CELL FAX
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S3lON M31A1t1 NV1d
#i2112J3d $ :33d
❑ ❑ lf'RU3d 3H1 SV S3ANdS NOIlVOIlddV 61141
ON 80A
S1lON NOlIJ3dSNI rIVNI1 KJNO aSIl t1OJDddSNI 11011OVd 81111 SaiON NOLL71JSNI ONIfIIVf11a 1100011
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