HomeMy WebLinkAboutP-14-759 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY ,1 ! tri217U y MIA DATE �f f PERMIT# P�1,' 7 r/
JOBSITE ADDRESS ` e!.%R.iiri�l% . m OWNER'S NAME' 0/-'a et//0cISP OWNERADDR /ESS ` ee TEL , , /FAX {
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL Er
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CLEARLY NEW:0 RENOVATION:u REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7 FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB / - — .
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM t m" ._ _ ^
DEDICATED GAS/OIUSAND SYSTEM -
DEDICATED GREASE SYSTEM + 1
DEDICATED GRAY WATER SYSTEM i-_____ —t C— G
DEDICATED WATER RECYCLE SYSTEM r ^— _f i— --S.------ I • I I
DISHWASHER - _ _ _ ,
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DRINKING FOUNTAIN —. —
FOOD DISPOSER
FLOOR I AREA DRAIN _
INTERCEPTOR(INTERIOR)
KITCHEN SINK / k
LAVATORY - . / i _ ,
ROOF DRAIN
' SHOWER STALL --- - - y -i - - , — - - — 1--
SERVICEIMOP SINK — ' --- - -- - __
TOILET - - _ _. -_
URINAL 4 4 q 4 F
WASHING MACHINE CONNECTION .+ i I 1 I i ,
WATER HEATER ALL TYPES _ -_ _ 1
WATER PIPING -- -- - --- - -
OTHER ,,7—,—yI� -- — ,— — _ ,—_
-
--_
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES D NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW -
LIABILITY INSURANCE POUCY Q • OTHER TYPE OF INDEMNITY 0 BOND El - •
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
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' CHECK ONE ONLY: OWNER ❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
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 per fun -• under the permit issued for this application will be in pr ' al ertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER'S NAME ken duarte LICENSE# 11012 SIGNATURE
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MPD JP❑ CORPORATION 0# 3541 PARTNERSHIP❑# =CA ----- - -;
COMPANY NAME duarte plumbing inc ADDRESS 37 Collins ave 11 EC )- ) `.r
CITY centerville STATE ma ZIP 02632 TEL 508-250- 76 , 9 (I1t5 't.,, _
FAX 508-775-9135 cat. EMAIL kenduarte37@hotmail.com
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