HomeMy WebLinkAboutP-14-825 .,' C ., MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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JOBSITE ADDRESS 35 t pcAn j OWNER'S NAMEM tlist_e..f
POWNER ADDRESS L____ , . . I TELL..__,:. 1FAXI. .�
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL[53-
PRINT
CLEARLY NEW:0 RENOVATION:D REPLACEMENT:121 PLANS SUBMITTED: YES 0 NO,
FIXTURES 1 FLOOR-' 6SM 1 2 3. - 4 5 6 7 - 8 9 10 11 12 13 14
BATHTUB - —
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
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DEDICATED GASIOILIS/WD SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
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DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY m _ ._
ROOF DRAIN -
SHOWER STALL
SERVICE I MOP SINK
TOILET
URINAL
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L BUILDING D�'IgTMENT - - -
uy�. iYJ INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES cg, NO 0
F YOU CHECKED YES,PLEASE INDICATE THE TYPE Cf COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
I.IABHJTY INSURANCE POLICY[S OTHER TYPE OF INDEMNITY 0 BOND p
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 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and intonation I have submitted or entered regarding this application we true the .T, ., my knowledge
anMassachusetts State Plunhlng Code and Chapter 1420oftheGeneral Laws.plumbing work and installations performed under the permit Issued for this application will be' all ' // . . of the
PLUMBER 'SNAMEI.,1` ,Lts- feh,et H--_ ilYt(nl\ _ IuCENSE#Lta7ds'M.l SIGNATURE
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COMPANY
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