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HomeMy WebLinkAboutP-14-694 1 ` C 1�V1 t) ) aP-b—cdg3i \`7 tame 1`1 -01414 -10 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK • --ifitot CITY I yet,r104-rpi. i... I MA DATE 1 4-119 i PERMIT# )V9 &9t/ JOBSITEADDRESS Qj1�o,5� IZAVeC " -jIOWNER'SNAMEI V.o4Ln-,Gn I P OWNER ADDRESS I TEL - FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL 9 RESIDENTIAL PRINT CLEARLY NEW:9 RENOVATION: REPLACEMENT:© PLANS SUBMITTED: YES El NO 17., FIXTURES? FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB llliMii.)_Srin1 I , i. I 1 . CROSS CONNECTION DEVICE (. ' T, _ 1 T' a ila DDEDICATED EDICATED GREASEAAS/01SYSTEMSYSTEM1011.11.111.0111011111101.i, , j d� j1,T ,� " DEDICATED SPECIAL WASTE SYSTEM �,� jSic IS inlini f j ..i Siis4 " DEDICATED GRAY WATER SYSTEM �� ���-i�,���;� ;(�;�y�ft DEDICATED WATER RECYCLE SYSTEM IsiL�1. „ ,jis,C ',,, S a :- sir,,011111.011101111111111111111.101.1 FINKING FOUNTAIN j)4�, `a ma DISHWASHER SS$ .. :t SS S.NO SOS FOOD DISPOSER ��� _ _ INTERCEPTOR K INTERIOR) "� �_ aI FLOOR I AREA DRAIN 1 C. Pm LAVATORY � ��1�:� +� OWF SS ROOF DRAIN .. . ROIS ,. .... _._. '; .' .._ SHOWER STALL 1111111011WWW101111a-Flogi. 00 OW' SERVICE I MOP SINK TOILET ��IlR � �. URINAL _ .., O. 11111111 _11/11113111111 lialla - , ll E • • yF.. .1_ _� larrSia I a tlrr,i�rA�rIII tiltriSie S 3 xn- 0 •' /, 1 I '1Ili, . r,_ ,_ By. // INSURANCE COVERAGE: 1 nave a currentliability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY V) OTHER TYPE OF INDEMNITY © BOND Q 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. t CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT 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 knowledge end that all plumbing work and installations performed under the permit Issued for this application will be Iiance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �/��---` �(J PLUMBER'S NAME FRIG T, w}J i y,_9 ,ILICENSE#I i 559 0 ,I • SIGNATURE MPW JP© 1. CORPORATION 0# .. JPARTNERSHIPQ# LLCQ# COMPANY NAME I,,io, Vernon whl� lADDRESS 1c�Tt II ( f, ' W.ndi OTT —1 Q. Q a4+4 t) I STATE W ZIP (. U4? TEL !�4145- II v�! 1 FAX CELL EMAIL _— . k. a- o Z . t 4 .. t , .. 2. o0 z PI. VI t - - — — — - - 5 w O W W Mk Ill . I- M w O et 0- ' LL 00 en O thi? CL _ k W - - - N ka g, w a P^ v J 0.. a a re N al i -- re C• 4 z N 0 1•r• a O a G o g FC