Loading...
HomeMy WebLinkAboutP-14-723 • irir /YIAP : PRReEc : \ 4S, - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK —" /' — M U MA DATE PERMIT# Pili—.743 -late CITY JOBSITE ADDRESS II Oak, A L 1ifF5 RI?OWNER'S NAME JA(,12— hl 4.C e I P OWNER ADDRESS WV Lti Jc k,Ji- aci • Cohn: 1 TEL " 14 Lo 4977 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL Q RESIDENTIAL gf?".°...°- PRINT CLEARLY NEW:Q RENOVATION:Q REPLACEMENT:[ PLANS SUBMITTED: YES Q NOD FIXTURES 1 FLOOR-. BSM . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I II I I, it .I J I r II i r 1 11..11.1. CROSS CONNECTION DEVICE WWI',S'111111111111111 II IEIII/III. 1 flfl DEDICATED SPECIAL WASTE SYSTEM IIIMM' � '�'maw _i_' � F i DEDICATED GAS/OIUSAND SYSTEM SW MI, , ion mgp ma, I I DEDICATED GREASE SYSTEM i ,ima. , DEDICATED WDEDICATED ATYER WATER.SYSTEM EM , . Ink -, DISHWASHER KINGFO *. SI " 'IaI f If_liEifl in sow FLOOR /AREA RE DRAL IM r--fii _r���= M 0 FOOD DISPOSER \ � V �h i��� l ���_��� KITCHENSINK O NI iM ___ __ LAVATORY V ,, ti n I � W.��I j_pp Mi. 3 +� ROOF DRAIN �V c J n a�in� 5 SHOWER STALLill J aake �'naiww M. SERVICE!MOP SIN cc m jij �, MS IIIIM NM IIIIII TOILET a�Iet �ali[ URINAL I PKI i 11111111.111111111MIIIII WASHING MACHINE CONNECTION Mt / WATER HEATER ALL TYPES Inisn,Nf WH� I N 4 WATER PIPING SSSS« OTHER it1� ouU IZ 11 �' manna' n V yew _I� r I PR,W n ' v V I 1 Li AA INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Q NO Q IF YOU CHECKED YES,PLEASE INDICATE TN/ PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW . I- LIABILITY INSURANCE POLICY L.:t OTHER TYPE OF INDEMNITY Q BOND CI . . J OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the O Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT 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 m knowledge and that ell plumbing work and installations performed under the permit Issued for this application will beinmp�wi(fi�II Pertinent prows of the Massachusetts State P+um_bling Code and Chapter 142 of the G neral Laws. rI OJ1 PLUMBER'S NAME MI 6Pi)V\(,(,,G !LICENSE# ,✓NP(21 SIGNATURE MPV JPD 1 CORPORA ION©# PARTNERSHIPQ# LLC®#_ COMPANY NAME i -tIALL c Built- J ADDRESS CITY y Lipkin I S STATE DM ZIP (9 240 1 ' ! TEL 775 q J I ! FAX CELL EMAIL