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HomeMy WebLinkAboutP-12-507 w OXE,l¢4Or-c,frGe'GrJ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK . MA. DATE JOBSITE ADDRESS PERMIT► L' C� Ts OWNERS NAME OWNER ADDRESS , Ali , I pPRR OCCl1PANCYTYPE COMMERCIAL TEL.—"'J's '.L--:= EDUCATIONAL Q RESIDENTUILN CLLARLY NEW.Q RENOVATION:Q REPLACEMENT FDtL/TRES 1 FLOORS-� PLANS SUBMITTED: YES❑ NO❑ an 1 © 3 Mn_© ainma Mlle__ 1111M__ 12_ -_ CROSS CONN DEVICE Mlle_=Mlle_ Mlle DEDICATED GASIOIUSANDSYSS S__ M__I �___ 1Ii_1 DEDICATED GREASESYSTEMSTEM an=anal DEDICATED GRAY WATER SY9 Ml __ �___ _ DISHWASHERDEDICATED WATERREUSESYS ___n�==Mlle_____ ORINIIONGF0Ut4TAN Mlle_111111111•11/4111111110011____ =_ FOOD WASTE GRNDERUNIT =Mlle__IAMBS M.._____ FLOOR/AREA ORAN _A'.n. 1/Mlle___ MINN INT1111111=1 MI ERCEPTOR INTERIOR _Ml_Ml_--i._Ml_ _ ROOFLAVADRAINNM Y �A�,r_Ml_MlMlMlMlle SHOWER STALL �AA�___ __—Mlle SERVICMOP E/ NK Mlle_ �A11111111111111111111111111 v_Ml_ TOILET __Mlle Ml���ram ♦ i��i��i�la Inrararava41.�■ WASHINOMACHNECONNECTION _ _MlA ate al INgtim""��'ar1 WATER HEATER TER CONNECTION TYPES amnia � �MliI�t1F�LWAIMli�[r' my IIIIII �MlMl��It:h\f i'�Iii�1UC41�� ,■Ile__ - IMIIII 111 NMI IIIIt mill agnamml WATER PIPING __ r_I .llMlMl111 a _Ml_le_M1 MIN _MINI_ 111111_IMlMlMl __ -__ MlMlU-CIhave icurrent liggiMikesurance olicy or b substantiala meets the requirements of MGL Ch 142 YES Q NO 0IYou have checked indicate the pe of coverage by checking the appropriate box below. UABIUTYINSURANCE POUCY OTHER TYPE INDEMNITY 0 BOND OINSURANCE WANE%I am aware that the licensee the Insurance ❑ WNER'S Massachusetts General Laws,and that my signature on this pernrt applcaUp, this baa by Chapter 142 of the SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0 • I hereby certify and al of the detail and information I have submitted(or entered)regard*this appligtlon are true and provision aaerietai Sbat all Antal work�InstalletbropedbrmedunderIMpermitIssuedkrthbe�raEatom best amy Plumbing Code and Chapter 142 of are General Lam applatlon"i be it Mbal Pertinent PLUMBER NAME�ii 7 ii,COMPANY NAME � 0 i �� I �l SIGNATURE ADDRESS 3 I O/foS,aNY _, A✓4 a CITY: STATE Ma ZIp ( � TEL: r afasFSM Cal: `' J FAX EMAJL ion . •d JOURNEYMAN 0 CORPORATION 0 S PARTNERSHIP Q s .�.r nucyFC�'�ONNOTES o.,o nrr:ICF USE ON1Y �'�Ballgaga..cnyIT10NNOTF� Yes a - resns"SERVES AS THE PERMM I ❑ FEE: PERMIT t_----- or NQFilfWNOTES I