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HomeMy WebLinkAboutP-14-470 I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITYktt, ,„ MA DATE jtO/t4hi. 3PERMIT#1'/9T9Zo JOBSITE ADDRESS ��,� � OWNERS NAME; jos osv�1 p �Ztq�2 OWNER ADDRESS Fres, nV Lt _ckcral_ __ Ts] TEL ' Lk QTS-.. ... �tAX TYPE OR OCCUPANCY TYPE COMMERCIAL Ll EDUCATIONAL _I RESIDENTIAL PRINT � CLEARLY NEW:© RENOVATION:( REPLACEMENT:r�. PLANS SUBMITTED: YES' NO: FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 • BATHTUB 1 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM t DEDICATED GAS/OIL/SAND SYSTEM4 I DEDICATED GREASE SYSTEM 8 DEDICATED GRAY WATER SYSTEM I w I- DEDICATED WATER RECYCLE SYSTEM i }'L DISHWASHER I DRINKING FOUNTAIN °' FOOD DISPOSER ,, t - , FLOOR/AREA DRAIN • I� INTERCEPTOR(INTERIOR) f :,4.1�� KITCHEN SINK I LAVATORY i r `t� 1= n ROOF DRAIN r SHOWER STALL I J 3C ."",lJ`•rjri}/ SERVICE " .1Af to..7P��(L TOILET pylI URINAL I L _ WASHING MACHINE CONNECTION t..,_ ( uX L3 :— ` �Ttt_°N7 WATER HEATER ALL TYPES I WATER PIPING ' ! OTHER s "I' I INSURANCE COVERAGE: I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES:,,,j ,j 1 NO X IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY El BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Massach G al Laws nd that my signature on this permit application waives this requirement. ( CHECK ONE ONLY: OWNER AGENT SIGNATURE OF OWNER OR AGENT \I I hereby certify that all of the details and information I 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 oomph.•.rf' ilh all • . r...nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �i``�' PLUMBERS NAME L_.SY S{y], j LICENSE# 10474 S RE MP El JP Ug • CORPORATION S# — ....1 NE', P 1# LLC #4.w. COMPANY NAME !ADDRESS y sot/1(�_4,4n L: CITY_Ft afah ...,JSTATEI.el k i ZIPPi i..r' .. ., .. TEL.771 11a rii8 FAX I I CELL I EMAIL l '