HomeMy WebLinkAboutP-14-812 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
4.-iY'�=ce In
%,..-11_,1� CITY[\ OrMIA C[l' 1_ I MA DATE .IQ 514- PERMIT# PPP— L A,
JOBSITE ADDRESSSt. ll!Y..1a'1noy CU\LY+ OWNER'S NAME Q x GQ Z.
P OWNER ADDRESS TELtoI7R(OIliLI-ltp FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL)
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Ekf PLANS SUBMITTED: YES❑ NO❑
FIXTURES-I FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB �I - !'- i---C__.� L . .
CROSS CONNECTION DEVICE -
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM r I,__ .,,, i DEDICATED GRAY WATER SYSTEM iir Ui _- ,11*i
DEDICATED WATER RECYCLE SYSTEM I r
_ r
DISHWASHER
DRINKING FOUNTAINRI� tai
'�"" ` IIn
FLOOR/AREA DRAIN
FOOD DISPOSER i�� I �I `,
INTERCEPTOR(INTERIOR) '
,_ h i
-_
KITCHEN SINK ' I��
LAVATORY r �
ROOF DRAIN f Jrr �rr
SHOWER STALL • ti
SERVICE I MOP SINK � 1 1
- � it
-
TOILET ill„ ill ,
URINAL
WASHING MACHINE CONNECTION
WA CR II CATERALL TYPE
WA! I., t T. J!IIIIIUII, '
OTE v - _I ' '/I r _ 1F
-v - -11M1-
it-- -r m a r
.. q _ , I
MALo�r7tr c,fr (` J _
By _ /l f INSURANCE COVERAGE:
I h: - • • r - • . Itcy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER:I 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 ❑ 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`` e and accurate to the best of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be In pliance with -: ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. J
PLUMBER'S NAME 1 142P - T (in r-mm A /LICENSE# la 97-i 1 SIGNATURE
MPD JP❑ I CORPORATION tom#1&4O ]PARTNERSH ., it# LLC Q#
COMPANY NAME (-,Em ?)Ihm bin ci ADDRESS I tot I 'in ark yo en}4_4.}4_4.CITto
Y /fit //-� STATE[ RT -1 ZIP ba.Sflp& TEL,, 9fi/— &39- 4k4/
FAX CELL EMAIL 74oXklrCYl 63 GrmYl PI,Urflbin 9 t Daryl
5R I5(q tnt
•
D
4
•
•
•
•
•
SHION M3IA32I NV Id
#LW213d $ :33d
❑ '❑ 11W2J3d 3Hl SV S3M133 NOLLVOIlddV SIR!.
• ON :,saA
S31.ON NOI, D3dSNI'IVNI3 A'INO 3Sfl 3D1,130 1103 M0133 531014 NOI1.73dSNI JNIH Wffld H0001.1
r