HomeMy WebLinkAboutP-14-674 MASSACHUSETTS UNIFORM APPLICATION FOR A P r- TO PERFORM PLUMBING WORK
v $ Li CITY Y Rr re\0Lt-H\ luk. DATE 1- -ERMIT# / fy—� g
JOBSITEADDRESS b CI 9 Lit11\a.r Ss' OWNERS NAME r•-+ p i-r e. r< h
POWNER ADDRESS TEL FAX_
TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ DUCATIONAL 0 RESIDENTIALd
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:l PLANS SUBMITTED: YES 0 NO 0
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FIXTURES 7 FLOOR- 1 BSMT 11 I 2 3 1 4 5 6 7 I 8 9 I 19 I 11 12 I 13 I 14
BATHTUB I I I I I
CROSS CONNECTION DEVICE I
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DEDICATED SPECIAL WASTE SYS I I I
DEDICATED GAS/OIUSAND SYS
DEDICATED GREASE SYS I I I
DEDICATD GRAY WATER SYS
DEDICATED WATER RECYCLE SYS I I I I
DRINKING FOUNTAIN I I I
DISHWASHER I I
FOOD DISPOSER I I I I
FLOOR/AREA DRAIN I
INTERCEPTOR(INTERIOR) I I I
KITCHEN SINK I I
LAVATORY- I � -
ROOF DRAIN" I
SHOWER STALL
SERVICE I MOP SINK • I I I _
TOILETI I I I I
URINAL I ( I I
WASHING MACHINE CONNECTION fI
WATER HEATER ALL TYPES I 1I
WATER PIPING I I I II
OTHER I I I I 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 No❑
IF YOU CHECKED YES, PLEASE INDICA HE 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 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 details and information I have submitted (or entered) regarding this application are true and accurate to the
best of my Knowledge and that ail plumbing work and Installations performed under the permit Issued for this application will be In
compliance with all PQrtinent provisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Law
PLUMBERNAME ) I n McCtC 1a� SIGNATURE . I
LIC# I S c1113 MP An. JP❑ CORPORATION ❑ PARTNERSHIP ❑U� LLC ❑#
COMPANY NAME CC i 1 'p ADDRESS: J'01 p1'I� "•� (1
CITY Sty L.V d, STATE LPS).)S1,3 EMAIL
TEL 56 8-3 17- S SZS CELL FAX •
P `= C5IVE:
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UI,.DING DEPARTMENT
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