HomeMy WebLinkAboutP-13-846 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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%lit -i CITY , ; / 0 MA DATE (4YQ/t PERMIT# 1" t✓+ `_
JOBSITE ADDRESS i F �• • IS7 fr. OWNER'S NAME (_—t ve
POWNER ADDRESS Ve_n US TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL Lt
PRINT
CLEARLY NEW:❑ RENOVATION:EJ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NOD
FIXTURES 1 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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FLOOR/AREA DRAIN IIESIIIIIMPOIMMOIRMOMMIlltilliMME
INTERCEPTOR INTERIOR sismomminimiliiitimilimiallillitmsmE
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LAVATORY .
ROOF DRAIN
SHOWER STALL - r -
SERVICE I MOP SINK I
TOILET
URINAL rr
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES L
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WATER PIPING �`r `, ,, �
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND ❑
OWNER'S INSURANCE WAIVER:lam 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 ONLY: OWNER ❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application ace true a • a urate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in pop lian�;',- h all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. { ,•
PLUMBER'S NAME ken duarte LICENSE# 11012 / , SIGNATURE
MP JP CORPORATIONO# 3541 PARTNERSHIP 0# LLC❑#
COMPANY NAME duarte plumbing Inc ADDRESS 37 collins ave
CITY Centerville STATE ma ZIP 02632
TEL'508-250-2763 r - I^ PI
FAX 508-775-9135 CELL EMAIL t11 Plfr . on+; a