HomeMy WebLinkAboutP-14-790 d. MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
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JoesriEADDRESs 1) 1 • %n-t fi-n e '�1pd OWNER'S NAMEGtr&yam �(,✓Itvo
POWNER ADDRESS U 9 )?cAt kw ki I`J TEL FAX
TYRE OR OCCUPANCY TYPE COlvIMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
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CLEARLY NEW:0 P NOVATION:0 REPLACEMENT:((y/ PLANS SUBMITTED: YES 0 NO 0
FIXTURES 7 FLOOR I BSBIT 1 2 I 3 I 4 I 5 6 7 B 9 I 10 11 12 I 13 14
BATHTUB I I I I
CROSS CONNECTION DEVICE I I_
DEDICATED SPECIAL WASTE SYS I I I
DEDICATED GAS/OILISAND SYS I I
DEDICATED GREASE SYS I I
DEDICATD GRAY WATER SYS I
DEDICATED WATER RECYCLE SYS I
DRINKING FOUNTAIN I • I
DISHWASHER ( I I
FOOD DISPOSER I
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• • INSURANCE COVERAGE
I have a current liability Insurance policy or its substanti quivalentwhich,meets the requirements of MGL Ch.142. Yes No❑
IF YOU CHECKED YES, PLEASE INDICATE❑ 4 E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE 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 th
Massachusetts General Laws,and that my signathre on this permit application waives this requirement
CHECK ONE 50XONLY: 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 t
best of my Knowledge and that all plumbing work and installations performed under e p it Issue for this a ication win be
compliance with all Pertinent`` nprovision of the Massachusetts State Plumbing Code and C p 4 of a eral
PLUMBER NAME-4A h 1 • A caw 4 e (( SIGNATURE �r
LIC 6 d/' MP JP❑ CORPORATION Q# PARI HIP ❑# LLC r 2.3
l Vf 11t4',¢ GY1h77,e ADDRESS./ --C.�/�INZ vela- / J
COMPANY MME �o
GIN POP? /2tf l STATEZIP 02 6 V'EMAIL
TEL rCJlr`l(>) Ley)) CEL FAX
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FIN renrf'TION NOTES
ROUGH PLUMBING INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY
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P AN REWEW NOTLS
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