HomeMy WebLinkAboutP-14-447 v
NC
t
t
J
1
M , \
\
Wsv \hi.
v
k ki
`
S \ o
d% h i O Q
l
MASSACHU"SETT'S�UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
y
ail j•.t ,4 ciw 61a(IY/1)701 (‘ n,� MA DATE IRC ^3O aI3 �PPEPJ T?/`/Ytt—yu 1
J0651TE KESS /3 D I*' a fa tic OWNER'S NAME roe 6o at
OWNER ADDRESS TEL FAX
TYPE OR, OCCUPANCY TYPE COMMEP ❑ EDUCATIONAL 0 RESIDE4TIAL
PRIG
CLEARLY NEW: RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO 0 .,
FIXTURES FLOOR-. 63M1111213141516177 B 9 j 10 I 11 I 12 I 13 14
BATHTUB I I
CROSS CONNECTION DEVICE I
DEDICATED EED SPECIAL WASTE SYS I I
DEDICATED GASIOIUSAND SYS I I
DEDICATED GREASE SYS
DEDICATD GRAY WATER SYS I
DEDICATED WATER RECYCLE SYS
DRINKING FOUNTAIN I I
DISHWASHER I
FOOD DISPOSER I
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY.. cR
I I I I
ROOF DRAIN"-
SHOWER STALL I I I
SERVICE/MOP SINK • I { I
TOILET
URINAL I I I
WASHING}JL&CHINE CONNECTION I J I I
WATER HEATER ALL TYPES I
WATER PIPING I{I
OTHER• F I I I I
$ III EI
• INSURANCE COVERAGE:
I have a currant liability Insurance policy or its substantial equlvalentwhich,meets the requiremens flhGlet�4E IY�f
IF YOU CHECKED YES,PLEASE INDICATEETTH E OF COVERAGE BY CHECKING THE APP OFFRI.AGTE BOX BELOW
LIABILITI'INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ 5010:3 0 2013
OWNER'S INSURANCE WANER I am aware that the licensee does not have the Insurance co g -• • • • - 7 0l the
Massachusetts General Laws,and that my signature on this permit application waives this requ rddrk kQ1r�Ga AA s i
e
CHECK ONE BOX ONLY: OWNER 0 AGENT 0 1/Ooc •
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 the
best of my Knowledge and that all plumbing work and Installations performed under the permit I sued for is application will be In
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chap 14 f th e ral Laws.
PLUMBER NAME ox //C/6 SIGNATURE
UC# 78/ PJkPF //ICORPORATION ❑# PARI SHIP ❑# LLC Q#
COMPANY NAME Celine io /ssw' ADDRESSYa SenLe €
CIN // AYSJnc %/ STATE/ t 'lUPod6l/p:EMAIL.9-n"e / er0 • C0
'
.
TEL cELL m/-s -
FAX
l -e
f4/�41/t -U21-7 0 _ej°J 30`