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HomeMy WebLinkAboutP-14-741 1- &:\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ill %i__ CITY ISO4a1 >'m'm ocA I MA DATE 6-4.4 PERMIT#_ f7Jyj xJ/_ JOBSITE ADDRESS 3'F tide-t_tx(Yvl tel , .1 OWNER'S NAMMEI nem, _--ii P OWNER ADDRESS # Iy lr TELT 362-0353 FAX I TYPE OR OCCUPANCY TYPE COMMERCIAL© EDUCATIONAL ❑ RESIDENTIAL6 PRINT CLEARLY NEW:Q RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ I-- ' FI IXTURES 1 FLOOR • BSM 1 2 3 4 5 6 7 El 9 10 11 12 13 14 BATHTUB S ,I __ _ �Il�F fl lial CROSS NECTION DEVICE � , ��I� iDEDICATED SPECIAL WASTE SYSTEM r ���'��l� r i � , DEDICATESPEAND SYSTEM ellitlialtalliallanallitraMMISISMIRile —.- DEDICATED GREASE SYSTEM rowans ni fl atensi a DEDICATED GRAY WATER SYSTEM 1 �I�r r r- r—,- DEDICATED WATER RECYCLE SYSTEM I S_I j _m— DISHWASHERI"-`t �� �i ,i f_. T DRINKING FOUNTAINRll _' I_ 's, _ ol l r� FOOD DlsposERr� SMSM� sint ll KI _ i lr 5i�llr— p —: INTERCEPTOR(INTERIOR) II� I��� FLOOR I AREA DRAIN KITCHEN SINK LAVATORY .r .f ,fir �r �� �r -1,-,--- I I i ROOF DRAIN 1, .� r SHOWER STALL wan 7 SERVICE I MOP SINK nene ia,.'' , _URINAL l II V .I ixTOILET r I WAWASHING MACHINE fi ��COtN�CE® i �' I ---- KKP`' OLe �- IV �l�' -- -- I - I�' " i �,�p a i. ---- OTHER Ll'� Y'fSJ0I � f _� r 1'. � - I, 20" DU ii_ut 16 I TA,�:NP - r INSURANCE COIVERAGE• ��' INif 'int i� I havc a cm reia Itdul Ity insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESZ NO Q IF YOU CHECKED YES,PLEASE INDICATE TIIE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABIUTY INSURANCE POLICY 53 OTHER TYPE OF INDEMNITY 0 BOND OWNER'S INSURANCE ,AIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massach s:r Genet-. aws,and that my signature on this permit application waives this requirement. -- CHECK ONE ONLY: OWNER e AGENT SI NATURE OF OWNER OR AGENT I hereby.:rtdy 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 .11 plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision or the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ! i PLUMBER'S NAME mAT)c J-Q_CL tic) _ LICENSE# if i 17 I / v riIcy SIGNATURE MP JP El CORPORATION#Ori-T-l(4PARTNERSHIPQ# LLC 0#I I . COMPANY NAME __ ,1 t;., ' , ' , d ADDRESS 3 �. c. i c iw [,b tUL' . CITY! 1:' ,:a tom..,. :\lf' ISTATE nin ! ZIP C0 . 7/n. -- TEL .56,5. tei,. 5 y,s2 J FAX 'bf 5,C5, CELL . EMAIL \`,pr-it; lut�lita grIe ur,Yincr.',v, t..,p \-. !I S31ON M3L\32I NV1d #1IWN2d $ :33d ❑ 0 1IW213d 3H1 SY S3/1213S NOIlY011ddb SIHI oN saA SJION 411NO 3511 HDI3d0 NO3 M013fl SALON NOI.LD3dSNl JNL81NIl'Id II911011