HomeMy WebLinkAboutP-14-684 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY \I/AC/AGO-n-1 MA. DATE 'i ( l-f �" PERMIT# NH- 9 (of
JOBSI T E ADDRESS H Z I,a LLLr tsfri S PATH OWNER'S NAME M•4 eTx^1 / A/\15
p OWNERADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES 0 NO
EA
FIXTURES 7 FLOOR-' BSMT 11 I 2 3 4 I 5 I 6 1 T B 9 10 I 11 12 I 13 14
BATHTUB
CROSS CONNECTION DEVICE r
DEDICATED SPECIAL WASTE SYS I
DEDICATED GAS/OIUSAND SYS
DEDICATED GREASE SYS
DEDICATD GRAY WATER SYS
DEDICATED WATER RECYCLE SYS
DRINKING FOUNTAIN
DISHWASHER
FOOD DISPOSER
FLOOR I AREA DRAIN I
INTERCEPTOR(INTERIOR)
KITCHEN SINK / I I_
LAVATORY-:-. / / •
ROOF DRAIN" • I
SHOWER STALL /
SERVICE/MOP SINK •
TOILE 1 I
URINAL
WASHING MACHINE CONNECTION
_._WA3ERHEA '`GRE
WATER PIPING' t/ V 3 / I
APR 17 11114 I I
• 1 - INSURANCE COVERAGE
Ileu . blitSTPSU nce policy or is substantial equlvalantwhich,meets the requtremens of MGL Ch.142. Yes No❑
• - • E INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND ❑
OWNER'S 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 waives 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) regardin• this application are true and accurate to t
best of my Knowledge and that all plumbing work and Installations performed under th l•ermit issue",for this application will be
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and C -r -r 14y"•, eneral Laws.
PLLIMBERNAME 4)£R-EX.- TCC LEJZC SIGNATURE //
LIC# LG0a2-- MP CI JP❑----CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY
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TEL CELL 5-b£3-Zf Z-7Z Y9 : FAX
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