HomeMy WebLinkAboutP-14-838 J .. . MASSACHUSEi fS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
+� , CITY i d P d I MA DATE O. PERMIT. piY- 7 ,7
JOBS 'ADDRESS CIW S A// OWN 'S NAME J�_.idin/
POIMIEP,ADORES / L -A / /I T TI agA;,
TYPE OR OCCUP.ANCYTYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDBf iAL IZY
PRINT
CLEARLY L7 NEW: RENOVATION:ElREPLACEMENT:❑ PIANS SUVA I I tU: YES❑ NO
•
FR—TURES-1 FLOOR.-- I BSMT 11 12 13 4 I 5 I 6 I 7 I 8 I 9 I 10 I 11 I 12 I 13 14
BATHTUB I I I I I
CROSS CONNECTION DEVICE I I I I I I I I
DEDICATED SPECIAL WASTE SYS I I I I I
DEDICATEE)GAS'/OILISAND SYS I I I I I I
DEDICATED GREASE SYS I I I I I I
DEDICATD GRAY WATE;SYS I I I I I I
DEDICATED WATER RECYCLE SYS I I _I I I I
DRINKING FOUNTAIN I I I I I I
DISHWASHER I I I I I I
FOOD DISPOSER
FLOOR/AREA DRAIN I I I I I I
INTERCEP t uR(INTERIOR) I I I I I .
KITCHEN SINK I I I I I I
LAVATORY--. I I • .I I I I
ROOF DRAM"' '
SHOWER STALL I I I I I I
SERVICE/MOP SINK • I I I I I
TOILET I I I • I I I
URINAL I I I I I I I
I WASHING MACHINE CONNEC11ON I I I I I I
WATERHEA ERALLTYPES I I I I I I I I
WATER PIPING 1 I I I I I I I
OJHER
tiryael h( 1 4z Ir
v- lirigi ci:7 vw e I I I 1
• INSURANCE COVERAGE:
I have a liability bility Insurance policy or Its substantial equivalent which,meets the requirements of MGL Ch.'142. Yes No 0
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 ❑
OWNERS INSURANCE WAIN/Et lam 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 •
Signatire of Owner or Owners Agent
I hereby certify that all of the details and information I have submitted dor 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 all nent provision f the Ma chusetfs State Plumb{ng Code and • -r 142 of Iii ental _nil
PLUMBER NNE rj�it 4 ,ch/e//SIGNATURE I i..-, - _ ///�v ��
LIC# ILZ27 IJP�y JP CORPORATION 01 PARTNERSHIP My LLC •#
A
/1"
/ A
COM NAME - r ! >/r / J.e ADDRESS /i .-/ ,c a -
cm,i - II/ / STATE.ii IZIP #- ? /=jAlL
e s l� _ �. 027- FAX
RECEIVED
JUN 232014 /jif
teasAllr 5 r • tV
• -•R fEr
By _
i?INAi,iNGPE_--.MN N
oT> s
ROUGHPLUMBING INSPECTION NOTES
THIS Pp GEI:ORiNSPL�CTORU EONS
Yes No
• CI h8-0/-9:9 rIL, 0 0
FEE: $_�
PERMR 11�—
Pi AN Rngi N
•
•
•
1 �'-