HomeMy WebLinkAboutP-14-327 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
Pt4-3Z
;a1 CITY SOtit14 Ylt2MOU`ll� MA DATE PERMIT#
JOBSITE ADDRESS 0-6 NAteVAgD sr OWNER'S NAME bIQ3AM MAY13-1EOW
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL EV
PRINT
CLEARLY NEW:❑ RENOVATION:0 • REPLACEMENT:p2 PLANS SUBMITTED: YES 0 NO 0
FIXTURES 7 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER •
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
•WA E I�IOt�y
OTR ER /II p_ l h
NOV 5 2013 ✓V
4C
LSU/LDI. str TMENF INSURANCE COVERAGE: .8 "pl
I h d ••licy or its substantial equivalent which meets the requirements of MGL • 142. les w- NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 4/1
LIABILITY INSURANCE POLICY IV OTHER TYPE OF INDEMNITY ❑ BOND 0 -42
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 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 complia e wi I Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME-DPW-PH SUWiVAA) LICENSE# /c28I-go "( GNATURE
MP sa'' JP❑ CORPORATION E1/# aypa PARTNERSHIP 0# LLC❑#
COMPANY NAME 1 . 6ULLIVA.II AJC--. ADDRESS I/OA NAUOVL ST j/AJ/T A
CITY fjAAJOvEI- STATE NA ZIP 0 339 TEL 18/"8'Il- 9g'12/
FAX 181-87/-5499 CELL loll-593-c&6 - EMAIL T3Ulmech ®ootrcosT, reit-