HomeMy WebLinkAboutP-19-1314 MASSACHUSETTS UNIFORM APPLJCATION FOR • PE- IT TO PERFORM PLUMBING WORK
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A, al /Y PERM # 'A71 5 t��{
P._ CITY ��`/�� nMA DATE 1.20P/9
JOB SITE ADDRESS — Car it& b OWNER'S NAME CQQ.t/4i �/u�
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OWNER ADDRESS . TEL FAX / -
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL d
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CLEARLY NEW:0 RENOVATION:d] REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO•e3
FA?URES 7 FLOOR—, BSM 1 2 3 4 5 6 7 8 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- LAVATORY NK • q_E IN F D j
ROOF DRAIN
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SHOWER STALL l 302013
! SERVICE/MOP SINK Ji
TOILET
URINAL _ oYH 1
BU L r`�' /yam.
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WASHING MACHINE CONNECTION —
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Di NO 0
IF YOU CHECKED YES,PLEASE INDICATE 1HETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY OTHERTYPE OF 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 ap?fication waives this requirement
• t CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
LU 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 Imowledge
and that all plumbing work and installations performed under the permit Issued for this application will be In compliance ' a Pertinent provision of the
Massachusetts State Plumbing Code� and C r 142 of the General Laws. fir,,
PLUMBER'S NAME 64//r// �U LICENSE# 7f 0 / SIGNAL�/T,JRE
MP Ei JP 0 !,,/✓ CORPORATI N/9# PARTNERSHIP /#'A'// LLC!!J 40/
COMPANY NAME�6n /div e4 Ag ADDRESS l/�J 6& d tY let ��/f/
CITY!-I�/Vig..4 !1//U� STATE/S ZJP o2Z f TEL 5f atm
FAX CELL EMAIL ✓
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