HomeMy WebLinkAboutP-14-588 :� • MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK 1
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JOESITE ADDRESS /g/ TRPT/M vt 5Akirg : 0' OWNERS NAME t nst tiL
0 P OWNER ADDRESS TEL FAX
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TYPE OR OCCUP.ANCYTYPE COOM ERCIAL❑
EDUCA ZONAL ❑ PESIDJJ N I )v PRIG NEIN:❑ • I�RENOVATION: REPLACEMENT: PLANS SUBMif TED: YES NO 0
CLEP.RLY
.1).- FDC1URE57 FLOOR-. BSMT 1 1 2 3 1 4 I 5 I 5 7 8 9 I 10 I 11 12 1 13 1 14
9,7''9, BATHTUB
CROSS CONNECTION DEVICE I I I I
DEDICATED SPECIAL WASTE SYS I I I I I
262DEDICATEDGAS/01USAND SYS I I I II
DEDICATED GREASE SYS I I I
DEDICATD GRAY WATER SYS I I I I
Cg1,1•/ DEDICATED WATER RECYCLE SYS I I I I
�T l( DRINKING FOUNTAIN I I I I
DISHWASHER I I I I
FOOD DISPOSER I I I I
FLOOR/AREA DRAIN I I I
INTERCEPTOR ON T EPJOR) I I I I I
KITCHEN SINK I
LAVATORY..... I I II I I I
ROOF DRAIN-
SHOWER
RAIN SHOWER STALL I I& I I I I
SERVICE/MOP SINK • I I I I I I I
TOILET I I I I I I I I I I
-
URINAL I I I I I I I_
WASHING WI,CHINE CONNECTION I I I I I I I I
WATER HEATER ALL TYPES
WATER PIPING I
OTHER I I II I I I I _ I t
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INSURANCE COVERAGE: - /
I have a current liability Insurance policy or its substantial equivalent which,meets the requlremen5 of Lrah�A4y,1 YeeSl�'N o C
IF YOU CHECKED YES, PLEASE INDICATEISL._
� THE TYPE OF COVERAGE BY CHECKING THE APPRO TE BOXBELO
LIABILITY INSURANCE POLICY [i OTHERTYPE OF INDEMNITY 0 eyBBOND fly'[ /t/1L.
OWNER'S INSURANCE WAJVERI 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 9/71 f/
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 th
best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be I
- compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER NAME kh4Oren �f$• SIGNATURE_ L�
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UC# 3Nogo MP JP 111-' CORPORATION Of PARTNERSHIP ❑# LLC ❑#
COMPANY NAME Nye. ft 4 4- N c c ADDRESS: I x1211 f12y /Ari
CITY tAA '-4°.2Ni nur- I STATE r4,44e
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