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HomeMy WebLinkAboutP-12-576 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 4H-4111. ‘Hy CITY JOSSREADDRES3 ������ INN DATE` O/C_PERMR/ is p ffit ar le t P t3F P OWNERS NAME T . III ' OWNER ADDRESS TEL: �`" 7 -. 'IOR OCCUPANCYTYPE COMMERCIAL EDUCATIONAL �FAX:C� y Nom, 0 RESIDENTIAL 0 W •p• i ❑ RENOVATION ❑ REPLACEMENTS V C;]aU-a 1 FLOORS-, en I PLANS SUBMfrIEp YES❑ NO 4 © 3 4 vv 9 10 nn RQ, NN DEVICE __��� _. 1 m®_® 14 t� 7.. T .� •:_ M _____ ________ DEDICATED GAS/OII/SANDSYS _________ ____ DEDICATED GREASE SYSTEM _ DEDICATEDGRAYWATERSYS _________ _ DEDICATED WATER REUSE SYS __ ==__ Ml DISHWASHER __ _ FOOD WASTE NM MIIII MOS __ONGFOUNTAIN .111 _ _ = ___DERUNIT ___ = FLOOR J AREA DRAIN INTERCEPTOR INTERIOR _ _ le_ ____NM= Me anKITCHEN SINK In _ LAVATORY ROOFDRAIN �______ _ SHOWER STALL _==_____SIIIMIIIIIIIIIIIIIMIanalalli__ SERVICE __ ISSN 111111111111 IMO 1111111111111111111111111111MIIIIIIIMIIIIMIIIIIIIIIMO ILET la 111111111111 ___ 111111 WASHINGMAONINECONNECTION _____ __ WATER PIPING E■_______ 111111111111 IZMIEDumizgail MU Ile MIN ______ immmala iINN 111111111111111111111111111111111 TIIMI 11111111111111101 11111111111101111111111111111 ManammilIIIIII Ihave acurrent -EC __�����_ insurance policy or Its substantial equivalent which meets the %Pio 0 if you have checked y,,please Indicate the type ofhertk"n MMGL Ch 142 YES ONO INSURANCE POLICY by OTHER TYPEINDEMNITy ❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am awn that the license.doesft the hums coverage required Massachusetts General Laws,and that my signature on this permit application web this requirement. by Chapter 142 of the SIGNA7UREOFOWNERORAGtM CHECKONEONLY: OWNER 0 AGENT 0 I hereby certify that al of the detele and Information I have submitted(or entered) regarding IN,Knowledge and that al plumbing at and Instalatone performed under thea� 0n are true and tol P t ofmyp of the Massachusetts Seib State Plumbing Code and Chapter 142 of the General L�aws�this a� WI �' en al Pertinent PLUMBER NAME:Ft f)( i S q q LICENSE if COMPANY NAME ife . ' learlf ,moi m SIGNATURE ADDRESS erC 05.4s Cmr: S; i (7 tan.. STATE Mal ZIP. TEL: FAX il CELL:C=3E14AIL• MASTER H JOURNEYMAN❑ CORPORATION DIE PARTNERSHIP❑4 LLC❑lE=I • ?tC r�u.. iHcvFC�'IONNOTE� B u amig�R1('MEONaIC Qnnl H cortlTlON NOTES yes No x632 SERVES AS THE PERS 0 0 Fes. 5- ----- PERMIT t------ r w pi EW NOTES ------------- ------------ ----------- 1 ----------- ------------ L