Loading...
HomeMy WebLinkAboutP-14-825 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK • 'Da- -.--? __Fj CITY 'AcAcc ncR \ MA DATE Q.) I tF5I IL PERMIT# pili_ £26-1 c51e JOBSITE ADDRESS Re, Crin5ecrlc\er• Orl OWNER'S NAMES p- if;,}-- eenoc€ I 6DP OWNER ADDRESS NAC ccc'n,*slch ?OctlTEL FAX WNW TYPE OR OCCUPANCY TYPE COMMERCIAL© EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW:Q RENOVATION:El REPLACEMENT:XI PLANS SUBMITTED: YES 0 NOQ FIXTURES 1 FLOOR-, BSM 1 2 3 4 5 6 7 8 9i 10 11 12 13 14 BATHTUB ` I----- DEDICATED SPECIAL WASTE SYSTEM �, r—� �) I!___ 1 ___1,T T � I T I_ _I II- CROSS CONNECTION DEVICE 1__T �,- �U�,� (� � DEDICATED GAS/OIL/SAND SYSTEM MAW, . - ifli I' - . I� 1" DEDICATED GREASE SYSTEM 1 IIB DEDICATED GRAY WATER SYSTEM 1, j, j Ili i ,_._1 ' II DEDICATED WATER RECYCLE SYSTEM DISHWASHER , ' I- • I 4 DRINKING FOUNTAIN __I . _ _ _ ',_.,_ FOOD DISPOSER • f Q r,� 11_11�� � 1- � __ �a1 1 r la FLOOR IAREA DRAIN _! V s _JA___ =J __ CTt - . _-i_ INTERCEPTOR(INT.•t `0,l /� 1 _ II 1 •_ I I _ 11 1_ I 7 i 1, I KITCHEN SINK G to �i le _ s_ _ , — I.� . I ROOF a•T _ —1' I — --al , —dr SERVICE i•P ' K Cod• r I TOILET �O\`� —T--------(1_1-____ LT r___I _ URINAL pJ` / � Il �I WASHING MACHI . ••• ECTION ____R 1t__JL Ii-1 __-1f'____,If WATER HEATER ALL PES _ (_ ;-.--_i ___u - _' WATER i 1 1 I,__1 -J __ -- UL=- • . OTHER PIPING , __.__ �''r_ 'I .._J ___.A . ... 1 ____i . __ . . ___ iM I"...... Q. . dI�I—..I ._ NIIt J IM�IMIIIMMEIi . tl_ 1. I . Ma= NOWINIMISIMIUMIN INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESici NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABIUTY INSURANCE POUCIM OTHER TYPE OF INDEMNITY D _ BOND ci 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 CHECK ONE ONLY: OWNER ® AGENT Q SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information 1 have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in mpl®iance with ertinent p vision oof the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - .Gf/lT .!. �/O PLUMBER'S NAME (Inv- S, K_\Pd . Q 1 t • jLICENSE# $ _ SIGNATURE MPlEr‘ JP[3 CORPORATION0# PARTNERSHIP Q# LLC 0# - COMPANY NAME Cta R,\ c-, R:ortt 1.1 cit( `N ADDRESS • 11T _1\41,0 ri S12-12-12 +- I CITY Ci:Aa ]lit L.P.ISTATE MS ZIP 3 p <j S TEL 5( -Lias -(03(05 FAX -- CELL a EMAIL -. l,f`(f