HomeMy WebLinkAboutP-14-738 MASSACHUSETTS UNIFORM APPLICATION FORA PER IT 0LF3J
PERFORM/ PLUMBING WORK(�
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JOESITE ADDRESS S v r �VJNER'S NAME�]
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TYPE OR OCCJP.NJCYTYPE COMMERCIAL EDUCATIONAL 0 RESIDcENTA%.
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CLEARLY c NEW:0 RENOVA11ON:0 REPLACEMENT: PLANS SUBMITTED:TED: YES 0 NO 0
FIXTURES 7 FLOOR- I BSMT 1 I 2 I 3 4 1 5 7 a s to I 11 12 I 13 14
BATHTUBI
CROSS CONNECTION DEVICE I ' I I I I
DEDICA i ED SPECIAL WASTE SYS I I I I
DEDICATED GAS/01USAND SYS I I I I I
DEDICATED GREASE SYS I ( I I
DEDICATD GRAY WATER SYS I I I I
DEDICATED WATER RECYCLE SYS I I I
DRINKING FOUNTAIN I I I
DISHWASHER I I I I
FOOD DISPOSER I I I
FLOOR I AREA DRAIN I I I I
INTERCF OR(INTERIOR) I
KITCHEN SINK I I I I
LAVATORY-- •
ROOF DRAIN-
SHOWER
RAIN- I a l I I ( I
SHOWER STALL I I I I
SERVICE/MOP SINK • I I I I l
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± OUILUINU ;/d ViLI`�I INSURANCE COVERAGE:
I have a .. ,, Y nth/Insure ce policy or Hs substantial equivaientwhich,meats the requirements of MGL CIL 142, Yes No❑
IF YOU CHECKED YES, PLEASE INDICATETHE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER I am aware that the licensee does not have the insurance coverage required by Chapter 142 of th
Massachusetts Ganerol Laws,and that my signature on this permit application waives this requirement
CHECK ONE BOX ONLY: OWNER 0 AGENT 0 •
Signature of Owner or Owner's Agent -rx
I hereby certify that all of the details and information I have submitted (or entered)regarding this application are true and accurate to t
best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be
compliance with all Pertiinent provision of the assachusetts State Plumbing Code and apter 14;of�¢e fnen raft Laws,, �.
PLUMBER -De,,U la I f`C rocc 1 A- SIGNATURE Wei
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MP[( JP El- CORPORATION 0# PARTNERSHIP 0# LLC D#
COMPANY NNAAME I V'e The 1,p I o M hp Pr. ADDRESS
crrY .i Dor* STATE r J` nPOat gal BAIL:
TEL VV CELL 37:19- g°t S - g a $ 3 FAX
PTNAL TNSP1;
TON OTRS
THIS MGR FOR INSPECTOR OR USE ONLY
NOTES Yes o
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