HomeMy WebLinkAboutP-12-559 . ! - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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L ; ay l_,3tr CITY )j1riothi 'f4{4 IMA DATE `//2-0//2- (PERMIT#Pit- s Sq
JOBSITE ADDRESS 75' Wij/woot4f_ V;//qq N
4. OWNER'S NAME Ehret,;. antehlnq _I
P OWNER ADDRESS J I TEL FAX I
aTYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL
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CLEARLY NEW:❑ RENOVATION:CI REPLACEMENT:EV PLANS SUBMITTED: YES❑ NOI'
FIXTURES 7 FLOOR-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB r i 11. 1 CROSS CONNECTION DEVICE , r,r r _ ,, la it
z‘ DEDICATED SPECIAL WASTE SYSTEM 1 7 - IF r I I �c
DEDICATED GAS/OIJSAND SYSTEM frCLI Ia
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DEDICATED GREASE SYSTEM
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DEDICATED GRAY WATER SYSTEM I (
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DEDICATED WATER RECYCLE SYSTEM I —e
DISHWASHER III _ r �"""'��,
DRINKING FOUNTAIN t,y _ '.'S
FOOD DISPOSER �� —� iaLI
FLOOR AREA
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INTERCEPTOR(INTERIOR)
KITCHEN SINK inn I ,, I(�
LAVATORY
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ROOF DRAIN r I -
SHOWER
SHOWER STALL
SERVICE/MOP SINK' iiii il 1 I 1 !I I ,
TOILET •
URINAL
WASHING MACHINE CONNECTION II MK
WATER HEATER ALL TYPES na , a
WATER PIPING Inisorg -,-1,-• laza:i
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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®1JO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYP OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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 ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details end 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. ht w n / /r
PLUMBER'S NAME 'LICENSE# 7799' I SIGNATURE
MP❑ JP❑ CORPORATION Ea</7 697,C.JPARTNERSHIP❑#IIIIIIIIIIIII LLC Q#
COMPANY NAME I4J7y. 2t c I ADDRESS 222. Mid- rot Disc
CITY y✓. yArirvll ISTATE QM ZIP 02073 1 TEL 31.)/-771-- 1703
FAX 5bg-77I-97/01 CELL EMAILI