HomeMy WebLinkAboutP-14-547 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
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- MA DATE z //if J i PERJJ�IT# i �7 - 7'170 2 " Joesr-EADDREss 33 IRowt5 ad OWNERS NAME bevy re/ Ot,n.-( $
7 I P OWNER ADDRESS TEL FAX
t -E OR OCCUPANCY TYPE COIJJt7EP,CIAL❑ EDUCATIONAL 0 RESIDENTIAL L'
lL! \ y I PRIM /
0 OO . r LEARLY NEW:0 RENOVADON:❑ REPLACEMENT:[�' PLANS SUBMITTED: YES 0 NO•
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W if • - RES 1 FLOOR-. BSI 11 2 3 4 15 I B 17 I B 19 I 10 I 11 12 I 13 I 14
LL' THTUB I I I I I I J
•'OSS CONNECTION DEVICE I I
DEDICAi rD SPECIAL WASTE SYS I I I I I
DEDICATED GAS/DIL/SANDSYS I II I
DEDICATED GREASE SYS
DEDICATD GRAY WATER SYS I
DEDICATED WATER RECYCLE SYS I
DRINKING FOUNTAIN I I I I
DISHWASHER
FOOD DISPOSER I I
FLOOR/AREA DRAIN I I I
B.ERCEEPTOR QNTEPJOR) I I •
KITCHEN SINK
LAVATORY-.••-
ROOF DRAIN--
SHOWER STA' I I I
SERVICE I MOP SINK • I I I I
TOILET I 1 I I
URINAL I I I 1 I I
WASHING MACHINE CONNECTION I I I I I
WATER HEATER ALL TYPES
WATER PIPING I I I I II I
OTHER I I I I I I 1
I I I f F
INSURANCE COVERAGE:
1 have a currant liability insurance policy or its substantial equlvalentwhich,meets the requtremen`s of MGL Ch.142. Yes 2 No 9
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ®' OTHERTYPE OF INDEMNITY 0 BOND ❑
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 BOX ONLY: OWNER 0 AGENT 0 •
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to th
best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be I
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER NAME Marl- 17ruenect'e44. SIGNATURE
LIC# I S2SI1 MP[/ JP❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME MID, P+I} ADDRESS: P, O, Be A 1'1 YT.-
CITY S. D-tnet;5 STATE MA- ZIP °• '° EMAIL.
TEL CELL $3¢ 3'ry "Mt. FAX
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r�mnr!`TiON NOTT•;S
`- ROUGE(PLUMBING INSPECTION NOTES TinS PAGE FOR INSPECTOR USE ONLY
Yes No
1 I Cs 0L SE: -SO 1 E _ 0 0
FEE:
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