Loading...
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-