HomeMy WebLinkAboutP-14-717 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
a I/ NA DATE /�' PERMIT# ✓ O —117
CITY L.. ✓i /�� ! `
JOBS/ADDRESS RR5 I 7- e Y i 0'NNER'S NAME tj ct/1�,LL7/
P OWNER ADDRESS 5711 i311/2-4- y-. nYPj(sc)rig-4-4
TYPE OR OCCUPANCYTYPE COMMERCIAL 0 1 EEDDUCA 10Nd-liAL 0 RESIDEAL V
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CLEARLY P NEW:0 NOVATION:0 REPLACEMENT:(�' PLANS SUBMITTED: YES 0 NO
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FIXTURES? FLOOR-. BSMT 11 I 2 1 3 4 I B B I 7 B 9 1 10 I 11 I 12 13 14
BATHTUB I I I I
CROSS CONNECTION DEVICE I I I
DEDICATED SPECIAL WASTE SYS I I I I
DEDICATEE]GAS/DIL/SAND SYS I I I I
DEDICATE GREASE SYS I I I I
DEDICATD GRAY WATER SYS I I I
DEDICATE WATER RECYCLE SYS I I
DRINKING FOUNTAIN I I
DISHWASHER I I
FOOD DISPOSER I I
FLOOR/AREA DRAIN I
INTERCEPTOR(INTERIOR) I I •
KITCHEN SINK
LAVATORY•:.. I I r I
ROOF DRAIN"-
SHOWER STALLI 1 I
SERVICE J MOP SINK • I I
TOILET I I
URINAL I I I
WASHING MACHINE CONNECTION I I
WATER HEATrRi,ALLTYPES / I I I
WATER PIPING I I IJ
OTHER I I I I
I I
• • INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalentwhich,meas the requirements of MGL Ch 142. YesNo 9
IF YOU CHECKED YES, PLEASE INDICATE HE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of th
Massachusetts General Laws,and that my signathre on this permit application waives this requirement
CHECK ONE BOX ONLY: OWNER 9 AGENT 0 •
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to t
best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be
compliance with allfinent proton of a Massachuse State Plumbing Code an 142 of the ental = ._. /
PLUMBER NAME , airy 4S/4/P SIGNATURE .��, 2 i i/ .
LIC # 11227 (e JP❑ CORPORATION 0# PARTNERSHIP ( C 0#
COMPANY NAME ,, PL l v/(/j f O/ a ADDRESS: ' , .�-v"I 11
CITY 1 I STATE A ZIP / .3 "EMAIL at "" n • 61•
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FEE: $---_----�' PERMIT It
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