HomeMy WebLinkAboutP-14-544 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
/y-
CTC�
l2{1ZDU '. Mab 7f/
A DATE I PEPJJIT# awe/
JOBSfi E ADDRESS i_ Iv' • _ , OWNERS NAME 5 o'e / /p,eu
OWNER ADDRESS 50. me IEI(�%)' .2622,c(2 Ax
TYPE OR OCCUPANCY TYPE: COMMERCIAL EDUCATIONAL 0 RESIDENTIAL$
PRINT
CLEARLY NEW:g RENOVATION:0 REPLACEMENT:K REPLACEMENT: PLANS SUBMITTED: YES 0 NO 0
FIXTURES 7 FLOOR— 1 BSMT 1 2 3 1 4 5 I 5 1 7 I 3 I 9 10 I '11 12 I 13 I 14
BATHTUB
CROSS CONNECTION DEVICE I I I I
DEDICATED SPECIAL WASTE SYS I I I I I
DEDICATED GAS/OIUSAND SYS I I I I I
DEDICATED GREASE SYS I I I
DEDICATD GRAY WATER SYS I I
DEDICATED WATER RECYCLE SYS
DRINKING FOUNTAIN
DISHWASHER I
FOOD DISPOSER I I
FLOOR/AREA DPAIN
o E- . .-
KITCHEN SINK I I I I
LAVATORY.:•
ROOF DRAIM' I I e0
SHOWER STALL SE_ I I I I
SERVICE/MOP SINK • I I I I I I
TOILET I I I I I I
URINAL I I I I I I
WASHING MACHINE CONNECTION I I I
WATER HEATER ALL TYPES I IMEN
WATER PIPING
OTHER
I I I I I
I I I
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which,meets the requirements of MGL Ch.142. Yes I] No❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 53 OTHER TYPE OF INDEMNITY 0 BOND ❑
OWNER'S INSURANCE WANER 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 detalis 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 all Perfinent provision of then Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER NAME {QC)A e�z+ ( is l-cO.IN SIGNATURE .19.0"4"-"C-
#
�
LIC# J0tic 0 MP®1e'7 O JP0" (� CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COUPANYNAME, V I�Y� �bw /h1 Q (,• ADDRESS: i _ i - Ca,. a 0,!
CITY1V1,Q
� YiNShuL.f STATE 042 ZIP D/CgcEMAIL pp�
TEL 574)$3a- dlSp G " i6'� sew ! E � VEFIS
hull... ...�
(FEB 18 2014
(MAI PA RTMt.+
E
.),/Jb,/e --240 -{/901