HomeMy WebLinkAboutP-15-1579 MASSACHUStI IS UNIFORM APPLICATION FOR A PLRMI I i u NG•cru KM rw iwiauvts wuKK
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JonaADORE.�S /! /j�/1/I/f�ilRLfT OWNER'S NAME [�cgY ktJA,Fe
OWNER ADDRESS If A/IIAt}1> Afv4tWT TEL FAX
TYPE OR OCCUP.ANCYT?PE COMMERCIAL 0 EDUCATIONAL 0 RESIDcJ�"li AIag----
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES 0 NO
•
FIXTURES 2 FLOOR-. I B5MT 11 12 13 14 5 16 17 1 e 9 I 10 I 11 I 12 I 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIALWASTE SYS I I I I I I
DEDICATED GAS/DIUSAND SYS I I I I I I I
DEDICATED GREASE SYS
DEDICATD GRAY WATER SYS I I I I I I I -
DEDICATED WATERRECYCLE SYS I I I I I I I
DRINKING FOUNTAIN I I I I I
DISHWASHER I I I I I I I
FOOD DISPOSER I I I I I I I
FL00R/AREA DRAIN
INTERCEPTOR(INTEPJOR) I I I I IF I I I •
KITCHEN SINK I I I I I I I I
LAVATORY
ROOF DRAIN"-
SHOWER STALL I I I I I I 1 I
SERVICE J MOP SINK • I I I I I I I
TOILET I I I I I I I I I I
URINAL
WASHING MACHINE CONNECTION I I I I I I I I
WATER HEAT ALL TYPES I I I I I I I
WAI—"tE^ PIPING
OTHER too//l I I 1 I I I I I I I
OW-t1 OW') !o/ALuigi I I I I I I I I
1 I l I I E1 I ' I 111 I
• • INSURANCE COVERAGE:
I have a current Labuity Insurance policy or its substantial equivalent which,meats the requlremenm of MGL Ch-142 Yes,B'(Jo 0
' IF YOU CHECKED YES, PLEASE INDICATE
THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOXBELOW
LIABILITY INSURANCE POLICY 1-27.- OTHER TYPE OF INDEMNITY 0 BOND ❑
OWNER'S INSURANCE WAIVER:l am aware that the licensee does not have the insurance coverage required by Chapter 142 of ti
Massachusetts General Laws,and that my signature on this permit appiieation waives this requirement
CHECK ONE BOX ONLY: OWNER 0 AGENT 0
Signature of Owner or Owner's Agent
I hereby cerEfy that all of the details and information I have submitted(or entered) regarding this appUcation are true and accurate to
best of my Knowledge and that all plumbing work and installations performed under the permit Issued for this appficafion will be
compliance with all Pertnent provision of the/Messachuseffs Stats Plumbing Code and C. -pter 142 of the General Laws.
PLUMBER NNE ')I vvt ✓iAn-r7 zoA/ • SIGNATURE /, _ - L•/iii
LIC#m-335IdP�JP❑ CORPORKT10N ❑ PAR HIP ❑# LLC Oft
COIJPANY NAME j Hn 1/1414n-cm ) r9 F /T , ADDRESS:,go K 1737
CITYC.0 ()2LemgK STATE/ill( ZIP(J,244") EMAIL
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