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HomeMy WebLinkAboutP-19-1314 MASSACHUSETTS UNIFORM APPLJCATION FOR • PE- IT TO PERFORM PLUMBING WORK 7�7 lx 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� 1U�L� OWNER ADDRESS . TEL FAX / - TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL d PRINT 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 - _ SHOWER STALL l 302013 ! SERVICE/MOP SINK Ji TOILET URINAL _ oYH 1 BU L r`�' /yam. . • i 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 ✓ Lfe ss-6 ti‘_ricz-Vin