Loading...
HomeMy WebLinkAboutP-14-722 MAP : PgAeEt : MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK §w=.c, 11j1 /ll T I ',..711107,e,' CITY [� 7,71.7,,7,37:7, '77" MA DATE y� ' , "Z C/ ' /Y PERMIT# /'� JOBSITEADDRESS I I/1h 6"9fe ird St J OWNER'S NAME yy11 k e. ofa Ie\heui I P OWNER ADDRESS 19 VIII e9CAV!'A 5t I TEL / g60 797 41M43 7 1 i TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL Q '. RESIDENTIAL Of." PRINT �,/ 4CLEARLY NEW:Q RENOVATION:Q REPLACEMENT:IJ PLANS SUBMITTED: YES Q NO[( FIXTURES Z FLOOR- BSMCROSS CONNECTION DEVICE a 1 2-air3 r 4 5 6 r 7 8 9 10 11 12 13 14 (d BATHTUB ll lia., .i-- , iii DDEDICATED GAS/01USAND SYSTEM 111111111a mug MMus...mg EDICATED DEDICATED GREASE SYSTEM , �mu 7M DEDICATED GRAY WATER SYSTEM asiiiiiii ann . DEDICATED WATER RECYCLE SYSTEM I - II I I —I 1 I FOOD DISPOSER u tn.1111,....g,iiiilinln M.IIMIMISRE.111111.11111.11,MI rKITCHEN SINK --- MI51.154 INISIMM.II=IIIM MSSMfi■Il�ttaS1I'MIS INTERCEPTOR - n� Pal i]U*.I , Ia'I d C ��IIa� Ila' LAVATORY ' o [i fl_. i S 1111111111111111111SF eJ ROOF • • >-- CLAN= �■[,aa s at €'P�Ifa a i sHows 7.- I ISI I I �` i II I #nzn =� OTHER . ( 'TYPESWATER HEATER ALL t C _ .. '/ '. _ V V 149 P1 .a __._ .. - .r. 'I _ ,.m. .. - -s a.__ - . _- t J - - - _. - - a li IL li _ 0 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Q NO Q IF YOU CHECKED YES,PLEASE INDICATE THE TY OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW V LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY D BOND Q 03 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 Q AGENT 0 ' SIGNATURE OF OWNER OR AGENT I hereby certify that ell of the details and Information I have submitted or entered regarding this application true and accurate to the best of knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be I compliance II Pertinent provisl of the Massachusetts State Plumbing14-124-41i Code al6nd,Chhapter 142 of the General Laws. Mr,rn, PLUMBER'S NAME 1[rL N/ J !LICENSE# 7/0t CJS I SIGNATURE MPth JP© CORPORATION_, LL Q# PARTNERSHIP Q# JCO# - COMPANY NAME a vvc.( Iy 1ACQ.UC� I ADDRESS Kitt r44Q p f e f"►�/�v '_- i �Cl CITY j-hj/jNLL 'STATE wag ZIP © Le,0 1 ( TEL 774 '-j / 73 FAX CELL' EMAIL • • telt