HomeMy WebLinkAboutP-14-823 MASSACHUSETTS UNIFORM APPLICATION FORA PERMrT TO PERFORM PLUMBING WORK
CITY 4- [ l‘ l:1/fl� rt-vs, MA DATE 6- I R- I ,!'PyP,MIT# il '--T '�._/�-
JOESITEADDRESS /( I UI/r CAn RO. OWNER'SN.NNEChisMy�-/t, -t7yol
1 OWNER ADDRESS //C WJ/inen //9( TRS.O7%73�8et7J FAX 1
TYPJLE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL,
PRINT
CLEARLY v NEW:0 RENOVATION:0 P. 'E LACEMENT:k PLANS SUBMITTED: YES 0 NO 0
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FIXTJRES1 FLOOR-. I SSW 1 12 13 4 1 9 6 1 X 8 1 9 1 10 I 11 I 12 I 13 14
BATHTUB
CROSS CONNECTION DEVICE I 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 I
DEDICATD GRAY WATER SYS I I
DEDICATED WATER RECYCLE SYS I I I
DRINKING FOUNTAIN
I I I I I
DISHWASHER I • / I I I I
FOOD DISPOSER I I I I I
FLOORIAREADRAIN I I I I I
INCEPTOR(INTERIOR) I I I I . I
KTCHEN SINK I I I I I
LAVATORY -. I I
—..-I ROOF DRAIN-- I I I I
L , r SHOWER STALL
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, "%-....„� SERVICE/MOP SINK • I I I
..I -I ,TOILET
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L#..1{ _ WASHING MACHINE CONNECTION I I I I
0I =-i WAT-' HEAT L --
HEAT- TYPES I I I -_
11! - WATER PIPING I J I I
L•-}�_ OTHER I I I I I I I I I
Lti I I I I I
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• • INSURANCE COVERAGE:
I have a current[lability Insurance polity or its substantial equivalentwhich,meets the requirements of MGL Ch.142. Yes'No 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY k OTHER TYPE OF INDEMNITY 0 BOND ❑
OWNERS 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 watves this requirement
CHECK ONE BOX ONLY: OWNER 0 AGENT 0 •
Signature of Owner or Owners Agent
I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to t
best of my Knowledge and that ail plumbing work and Installations performed under the permit Issued for this application will be
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 42 of the Gene aws. `
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PLUMBER NAME \--✓\.00 6 cA s c\c7 /AA) SIGNATURE —;
UC#/A050 IVP iv JP❑ CORDO TION g# PARTNERSHIP ❑tt ❑;#
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COMPANY NAME r a . -.de 1„ , ADDRESS Gy a./22/ ..„/ ,
CITY -r.7471a_�1 0- a STAS zIR0/.51a 1 EMAIL.
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