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HomeMy WebLinkAboutP-14-840 MASSACHUSE I i s UNIFORM APPLICATION FOR PERMIT TO PERFORM PLUMBING WORK r" `• CITY arM04.4-4" A,, MP. DATE�/ co 2 y I PERMIT#1 /t ^ u�0 JOBSTEADDRESS 53 !vo(rs.�' Edtts• 7. OWNERS NAME &Y--//7 d e /teak/ tic it f P OWNER ADDRESS RO C'n5S Ill a 'rat"5 7-7-• FM TYPE OR OCCUPANCY TYPE C011vU ERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL-R2 PINT CLEARLY NEW:0 RENOVATION:0 REPLACEMEIdia PLANS SUBMI i I ED: YES 0 NO ❑ FIXLIRES1 FLOOR-, I BSIAT I 1 2 3 4 1 5 6 I 7 6 9 10 I 11 I 12 I 13 14 BATHTUB CROSS CONNECTION DEVICE I I I I gDEDICATED SPECIAL WASTE SYS I I I I I N. DEDICATED GAS/OILISAND SYS I I I I I DEDICATED GREASE SYS I I I I I DEDICATD GRAY WATER SYS I I I I I DEDICATED WATER RECYCLE SYS I I I I I DRIICING FOUNTAIN I I I I I DISHWASHER I I I I I FOOD DISPOSER I I I 1_-------J--_______ FLOOR!AREA DRAIN I I I I I INTERCEPTOR rRCEPTOR(INTERIOR) I I I I ' I KTCHEN SINK I I I I I LAVATORY..... I I I I I I ROOF DRAIN-- I I I I I SHOWER STALL I I _ I I I SERVICE/MOP SINK - I I I I I I TOILS I I I I • I I I URINAL I I I I I I I I WASHING MACHINE CONNECTION I I I I I I I WAT eEt HEATER•ALL TYPES X WATERPIPING I I I I I OTHER I I I I I I I I I . I I I I I I I I I I I • • INSURANCE COVERAGE I have a current Habi tv Insurance polity or its substantial equivalent which,meets the requirements of MGL Ch.14L Yes IiZNo 0 IF YOU CHECKED YES, PLEASE INDICATETHE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY& OTHERTYPE OF INDEMNITY 0 BOND ❑ OWNER'S • - - o-•I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of ti- lt FM = I - - and that my signatire on this permit application waives this requirement — CHECK ONE BOX ONLY: OWNER gal< AGENT 0 • - • - • • er or Owner's Apert I hereby certify that all of the details and information l have submitted (or entered) regarding this application are true and accurate to t best of my Knowledge and that all plumbing work and Installations performed under the permit issued for this application will be compliance with allPertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of thee'General Laws. PLUMBER NAME Robert-t- /AN15 Yet. SIGNATURE '/ S e> '✓ 414 LIC#Ott 33g he IJP' CORPORATION 0# PARTNERSHP Ort LLC 0# COMPAN-Y, 'ENAME &obs Plu4i `'i 7 +e / ADDRESS: SP L�Gt k - Rd Cry CIL` Twnw STATE _ ZIP 02613 EMAIL' .,. :.r� � — 77ti - .LS3 Still CELLI- ... Ax /not) 1 JUL1 ' -. . -__1 • o�ltoiric rat, L • • • St[Ma 1 21 d — —IllMWHJ7d —$ :ggi O "1= I S? 6-A S 10 YO ''8 'f ON BM N .LO211 Nl A'INO`al a 1101.0 JS 1210'1�IOY,J Sll1J. 9:11.1.0N9:11.1.0N NO113261SNI DNILUAIf17.J 110R021 SaI0 V IA •