HomeMy WebLinkAboutP-15-3943 vC2
MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
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CITY UWa /� MA DATE i� litV PERMIT Nitteislp3�y3
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JOBSITEADDRESS 119/0, iZ# a OWNERS NAME C /&r(QY-1 Tn--3
P OWNER ADDRESS LOP✓4)2_ TEL q 7/'4 ( FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL Pc EDUCATIONAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
FIXTURES 1 FLOOR-. BSM 1 2 3 4 8 8 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOORI AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
—SERVICE I MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION--7711
(,'NATER HEATERALL'TYPES: n l •
ATERPIPIN I 1
OTHER rick.acs,7 eveir"
I JAN 14 2015
t- -- /Y,J ,I INSURANCE COVERAGE:
have a curren lability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 1 -110
IF YOU CHECKED YES,PLEASE INDICATE
�THE
TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POUCY (y—" OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:1 am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
1 hereby certify that all of the details and infomtation I have submitted or entered regarding INS application are true and accurate to the best of my knowledge
and that all plumbing mak and Installations performed under the permit Issued for this application will be Inlance v53101 Pertinent provision of me
Massachusetts State Plumbing Code end Chapter 142 of the General Laws. 7"
PLUMBER'S NAME LICENSE A q015-- SIGNATURE
MP 111 0 CORPORATION ail 3PI& PARTNERSHIP❑U LLC 0 R
COMPANY NAME dd Y ecI /'c4. ADDRESS 2 i U-ec n A vim!
CITY .. �f pn�.c sim STATE )UV ZIP 0' a et TEL r5t'h 43c r— >s o/
FAX -0S --7 8 CELL 9S—,9^ c/rei er EMAIL <p Q (a,/ rad) rt Pr(latest- COP-.