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HomeMy WebLinkAboutP-19-3241 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK . Ij. CITY '�GiLi'tJ2r� MA DAT0 r/t PERMIT* MPF-8-630 JOBSITE ADDRESS iy OC "friL`i>A f 446',4 1/aCti,.' OWNER'S NAME Reif, I G.t°U��/if OWNER ADDRESS /4:?• Pia, 24t TEL ✓ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW:0 RENOVATION:, ] REPLACEMENT:0 PLANS SUBMITTED: YES ❑ NO Pit FIXTURES 1 FLOOR—I BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM • DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM • DEDICATED WATER RECYCLE SYSTEM DISHWASHER • DRINKING FOUNTAIN FOOD DISPOSER _ FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK / LAVATORY • ROOF DRAIN SHOWER STALL • SERVICE I MOP SINK TOILET URINAL ,T" . ' WASHING MACHINE CONNECTION . I• • ' WATER HEATER ALL TYPES ; I V 7 - ., (J>J WATER PIPING I OTHER WILD fff frARIMENT INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES al NO 0 IF YOU CHECKED YES, PLEASE INDICATE �THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY I?! OTHERTYPEOF 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 ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT 1:Z1 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 an plumbing work and installations performed under the permit Issued for this application will be in compUan with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAMEv(ce.9r 6(`7�tto�j LICENSE# #©f 2 iG" SIGNATURE MP J� JP❑ CORPORATION❑it PARTNERSHIP❑.# LLC E(# ihi COMPANY NAME6at �}'02c ADDRESS �o> /� 1 �/-y CITY 7.112/ !/ STATE44 ZIP 06' i'e#97 TEL lag P/!3 FAX CELL EMAIL • -/t r / --NiC1C2d1 W./ MON AkaIkriX NTH a---) P/ f7 [[TT .1 J II 11W213d $ •33d ``77 ❑ 0 L1A1 83d 3H1 SV S9A213S NOIIV3I1ddV SIHI oN saA S�SON 1.10I1.12LdSNI gVNIdA KIND TSfI t70I�T10 a041 M07�g S�. om HoupaaSNI oMIaWfl'Td HOf10II