HomeMy WebLinkAboutP-14-676 I
MASSA1HUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
city �a/rtov1J NA DATE y`g I PERMIT ~C�70.
. JOSSITEEADDRESS Il S"kin rt5•,dc dr OWNERS NAME ncvck-Las_ Az-col
6� P OWNER ADDRESS 1` r TEL 5—ST?37/1e9FAx
/! TYPE OR OCCUPANCY TYPE COOT M —/ERCIAL 0 EDUCATIONAL 0 RESIDENTIAL its"
PRINT
CLEARLY NEW:0 RENOVATION:PI REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
FIXTURES'I FLOOR-+ I BBS 11 12 13 14 5 B I 7 B I 9 10 I 11 I 12 I 13 14
BATHTUB I I I I I
CROSS CONNECTION DEVICE
I
DEDICATED SPECIAL WASTE SYS I I I
DEDICATEE/GAS/OILISAND SYS I I I I
DEDICATED GREASE SYS 1 I
DEDICATD GRAY WATER SYS I I
DEDICATED WATER RECYCLE SYS I I
DRINKING FOUNTAIN
DISHWASHER I - I I I
FOOD DISPOSER
FLOOR/AREA DRAIN I I I I
NTERCEPTDR(INTEPJOR) I I I I
KITCHEN SINK I I I I
LAVATORY.-'-. I ) - I
ROOFDRAIN--
SHOWER STALL I I 1_
SERVICE/MOP SINK •
TOILET I I -
URINAL
WASHING MACHINE CONNECTION I I I I I 1
WATERHEATERi ALL TYPES I I I 1 I
WATER PIPING I
OTHER I I I I I I I
I I I I
I I I I I_ I
- INSURANCE COVERAGE: 4
I have a current liability insurance policy or its substantial equivalentwhich,meets the requirements of MGL Ch.143. Y J:i No 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND ❑
OWNER'S INSURANCE WANE2: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 BOX ONLY: 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 the
best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be It
compliance with ertinent provision of the Massachusetts State Plumbing Code and - of the eneral Laws.
PLUMBER NNE \� ^ u 7 (--;,,....10., SIGNATU 4e 4
11111 —
LIC# P-2-9y MPI�JP❑ CORPnORM1OON ❑# PARTNERSHIP t❑# LLC ❑#
COMPANY NAME QYJ 9•�i r(X I C fit/��1 ADDRESS: C d� `0 2'5
CRY 1V East Art �+, STATE /`4 MP 02G S/ EMAII.
TEND Ie_237-39r•7 ,f9---
CELL F
RECEIVED
rill/112014 4 I
BUILDING DEPAHI MINT - ,n jl,
or. —
�Gff p`6 on - y//4�y
•
•
ff•
•
•