HomeMy WebLinkAboutP-14-591 MASSACHUSETTS UNIFORM APPLICATION FOR A^P/ERMIT,T/O PERFORM PLUMBING WORK I
.•r ? CITY Y&/t 4,f0 o 's4{/ � , MA DATE'Fat `/7 PFFiMRm //7—s l/
` - JOBSITE ADDRESS Pi �oU1.1'4 5e o ren 4 OWNERS N.AMEri4 S ifi.ICo&af
POWNER ADDRESS TEL FAX J
6\Q T YPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL Q
11�` PRINT ^/
CLEARLY NEW:0 RENOVATION:(l REPLACEMENT:0 PUNS SUBMITTED: YES 0 NO
1' 94� FD.TURES 7 FLOOR-' I SSIT 11 I 2 3 4 5 � 6 7 6 9 10 11 12 13 14
BATHTUB I I I
CROSS CONNECTION DEVICE I I I J _
DEDICATED SPECIAL WASTE SYS I I I
DEDICAT GAS/OIL/SAND 515 I I-
I I
DEDICATED GREASE SYS I I I
DEDICATD GRAY WATER SYS I I
DEDICATED WATER RECYCLE SYS I I I
DRINKING FOUNTAIN I I , I I
DISHWASHER _
FOOD DISPOSER I I 1
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) I ( I I •
KITCHEN SINK I I I I
LAVATORY-••••. I I I
ROOF DRAW- I I I
SHOWER STALL I I I I
SERVICE/MOP SINK • I I I I I
TOILET I I I._ I I
URINAL
WASHING MACHINE CONNECTION I I I I I I
WATER.HEA MALLT1PES I I I I I
WATER PIPING I / I IOTHER I
860/C 5`u`; I I I I I ' I E
- • INSURANCE COVERAGE:
I have a currant liability insurance policy or Its substantial equivalsntwhich,meats the requlremen's of MGL Ch.142 Yes 'No❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOXBELOW
LIABILITY INSURANCE POLICY 2{ 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 signature on this permit application waives this requirement
CHECK ONE BOX ONLY: OWNER 0 AGENT 0 •
Si.nature of Owner or Owner's A•ent -
I hereby certify that all of the details and information l have submitted (or entered) regarding this application are true and accurate to t1
best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be
compliance with all Pertinent provisioRof the Massachusetts State Plumbing Code and Chapter 14 the General Laws.
PLUMBER NAMEdeft/-Yoze, c SIGNATURES0 de/049 G9 S /
LIC# Beg�'O MP(? JP❑/�, /CORPORfAAi ON 0# PARTNERSHIP ❑S UC c,Q/
COMPANY NAME .....,...<,,,,/,
YpKI�✓rt//44- G A�DDREEss:/=L 6.741.49
Cm,/0/-1/'��2i"`L, STAT ZIF�'P6' % EMAIL
TEL CELL 1;19.1 o ic ; U C Y 1
ii
MAR 12 2014 T
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