HomeMy WebLinkAboutP-14-682 MASSACHUSET-f•S UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
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JOBS r ADDRESS J t /t 4 E �OOW N RSS A E 7;:024.01
p OWNER ADDRESS YEC✓ _ Le/ ���rAY,
0 --4---IE OR OCCUPANCY TYPE COIVJdERCIAL❑ EDUCATIONAL E RESIDB�IAL[I
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0 :I .;r I`C Y NEW:0 RENOVATION:❑ P.E,SLACEIVENT:12 PLANS SUBMITTED: YES 0 NO
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12ict `aICATEEDSPECIALWASTE SYS I I
DEDICATED GAS/OIUSANDSYS I I
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-DEDICATED GREASE SYS I
—'-DEDICA T D GRAY WATER SYS
DEDICATED WATER RECYCLE SYS I
DRINKING FOUNTAIN I
DISHWASHER / I
FOOD DISPOSER
FLOOR/AREA DRAIN I I
INITi ERCEPTOR(INTEPJOR) l I •
KITCHEN SINK /
LAVATORY= I
ROOF DRAIN" I 1
SHOWER STALL /
SERVICE/MOP SINK •
TOILET / I
URINAL
I WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES I
WATER PIPING I I II
OTHER
I I I
I I I I I _ I
• ' INSURANCE COVERAGE:
I have a current nobility Insurance policy or its substantial equivalentwhich,meets the requirements of MGL Ch.142. Yes irlo❑
IF YOU CHECKED YES,PLEASE INDICATE E TYPE 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 th
Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE BOX ONLY: OWNER 0 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 unde, the permit issued for this application will be
compliance with ertinent ro ' ionof Massachusetts Plumbing77 Code and = 142 of the; eral :
PLUMBER NAME dirt P� (,V es:st •P// SIGNATURE ,Gig. - _ i/./ I'Al //
LIC# /MI 7 I j{1 JP❑ CORPORATION ❑# PARTNERSHP ❑ft .LLC #
COMPANY C. . A.' rr ' ADDRESS: I� / v
CITY I . e. .1 . STATE at ZIP 4 ?/C (Z9 0 Ci-; lir'e
TEL ,-4-‘`f-7S?Da CELL679)l 3l1-,2c2 7 FAX 'a2/7J
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THIS PACE FOR 1NSPEaOR USE ONLY
I7INA iNS 1;CTION NOTES
ROUGH PLUMBING INSPECTION NOTES
Yes No
TRS • LC IOi, S VESA - Eli, D ❑ _
FEE: S_— -- PERMIT P____----
pi ANREVIEW NOTES
•