HomeMy WebLinkAboutP-14-156 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
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Cf•y 1// ry h o p0)-)- �' MA DATE Cl/J% 2109 PERMIT# p�v/yrs
JOBSITEADDRESS)UO A /.17 4'n4 Qt LN, OWNERS NAME 60-Ar80 alr) a
POWNER ADDRESS 1414.2-(_, TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL[ '
PRINT
CLEARLY NEW:0 RENOVATION:gl REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO 0
•
FIXTURES 2 FLOOR-. BSMT 1 1 2 3 I 4 I 5 6 1 7 B 1 9 1 10 11 1 12 13 14
BATHTUB I I I I I I
CROSS CONNECTION DEVICE I I I I I
DEDICATED SPECIAL WASTE SYS
DEDICATED GAS/OIUSAND SYS I
DEDICATED GREASE SYS
DEDICATD GRAY WATER SYS 1 I
DEDICATED WATER RECYCLE SYS I
DRINKING FOUNTAIN
DISHWASHER
FOOD DISPOSER I I I I
FLOOR/AREA DRAIN1(?1 r? _
INTERCEPTOR(INTERIOR) I �9 l5
KITCHEN SINK
LAVATORY..'.. I • (1r2 C 6' 13 UJ I II
ROOF
SERVVICEIMOP SINK • I I
SHO
TALL
I UDItiC1181,11T
1Y�� 1
�._TOILET
URINAL I I
lav I
WASHING MACHINE CONNECTION I
I i I I I
WATER HEATER ALL TYPES I
WATER PIPING {II
OTHER I I I I I I
ic.,ist Sym):A, I Il i I I I II I I
• INSURANCE COVERAGE:
I have a current Iiablity insurance policy or its substantial equivalent which,meets 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 0 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 ❑ 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 142 of the General Laws.
PLUMBER NAME\ ))9_6:1/, prc\— SIGNATURE S
LIC#S 07 J ( /� MPP❑ JP I� CORPORATION ❑# PARTNER P ❑# LLC ❑#
COMPANY NAME J9vt C_'l pink )ht ADDRESS: 6 l9r,i9(s-ci—
CryAer, .f7C" STATELY& EP_d 1) EMAIL
TEL to)-1 or r)15 CELL FAX •
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