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Home My WebLink AboutP-12-583_/ * Iw off Svc«..-ksi • MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM PLUMBING WORK �'��- CITY MA. DATE©M1 PERMIT/ 8 -51.3 JOBSTTEADORES9 P OWNER'S NAME I. OWNER ADDRESS: �_-----,._ T nrr PRIIE OR OCCUPANCY TYPE: COMER= ra ainsmis FAX:E=1 � EDUCATIONAL 0 RESIDENTIAL 0 CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: FIXUTRES 1 FLOORS-' �+J 1 2 3 PLANS SUBMITTED: YES❑ NO _ vvnuvv 9 10 v® 13 CROSS liti2CONN DEVICE ______Min �u aa—1111111 _= DDD DEDICATED lt/SA SYSDEDICATED SPC-CIAL TEM MI— �� IIIIIIIIN �� DEDICATED GREASE SYSTEM ��_�_�� e 1111111111111 MI DEDICATED GRAY AYR REUSETER SYS all _____�MI DISHWASHER _____Malin =_______ DRINKING FOUNTAIN ____ __ FOOD WASTEGRudDERUNR ;� ___�___ FLOOR/AREADRAIN ,- n ___ INTERCEPTOR INTERIOR �' MIMI 111111 13 LAVATORY / n _e fr ==__�__ ROOF DRAIN //O7 1 JD�,ir, 1 MI 11111111M1111111111111111111•11 TRICE/MOP SINK I p. _________En Ina nil_ TOILET ®A3HINGMACHINECONNECTION ��_ __�� IMO 1101111111 WATER HEATER ALL TYPES _______________� 111111 WATER PIPING ____ �- ---11101111111111111.11 - Ilameal I have a current j[ policy a Its substantial equivalent COVERAGE ��ilr�'fZ� equivalent which meets the reqWrements If you havecheckedyflpleaseindiatethetypeofcoverageby �Bs appropriate box below. aMGLCh11ID Yk�awn fl, LIABILm INSURANCE POUCYV OTHER TYPE INDEMNITY MAY ili OWNER'S INSURANCE WAIVER I an aware that the licensees Insurance p 0 4.2012 Massachusetts General Laws,and that my signattre on this permit application mins this required 112 ofthe 'CPI'_ SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT I hereby cerW1'that al of the details and Inbnna0on l have submittal(or entered)regarding 1thh app�katlon are true and accurate to the beet of my Knowledge and that al plumbing pork and hataltallons performed under the Det provisbn of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ; a h lkadonplana with all Patient PLUMBER NAME LICENSE I COMPANY NAME rmana SIGNATURE CITY: •� ADDRESS: /J CITLZWYZERsure Mil ZIP: 6- .3 2 FAX EZI MASTER Ili JOURNEYMAN 0 CORPORATION❑I 1::::::1 PARTN �'•`G-_ ClLLC 0;fC7 -----S a o • : 00