HomeMy WebLinkAboutP-14-456 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK..--.. i
Cfix 74ta gG(!/7 /- / MA DATE �'C� ' / PERMIT x/_ 4'_
JOESft(/ADDRESS /SZMich/ L �/ OWNERS NAME///4(744
OWNER ADDRESS TEL FAX •
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 PESIDE1TTALg
PRINTNEW:0 RENOVATION:0 REPLACEMENT:Ig PLANS SUBMI T tED: YES 0 NO 0
•
CLEARLY c
FIXTURES 2 FLOOR-. I BSMT 11 2 3 4 5 I B 7 B 9 I 10 I 11 I 12 13 14
BATHTUB I I
CROSS CONNECTION DEVICE I I I
DEDICA i rD SPECIAL WASTE SYS I I I
DEDICATED GASIOIUS,WD SYS I I I I
DEDICATED GREASE SYS
DEDICATD GRAY WATER SYS I f
DEDICATEE WATER RECYCLE SYS I
DRINKING FOUNTAIN I I I
DISHWASHER I I I
FOOD DISPOSER I I I
FLOOR 1 AREA DRAIN
INTERCEPTOR(INTERIOR) I I I
KTCHEN SINK I
LAVATORY I I I I
ROOF DRAIN-- I I I I I
SHOWER STALL I I I I I
SERVICE 1 MOP SINK I I I I I I I I
TOILET
I I i II I I
URINAL I I I I I I
.27, ON I I I
W� � r I I I I I I
0 EV/ 14 50/ /Pit I
AIN 0(1 Mil I I I I I
ggteARTmEN INSURANCE COVERAGE:
1 niave aa currant fiablitvl• oe policy or its substantial equivalent which,meets the requirements of MGL Ch.142 Yes lI:(No 0
_...-
lir YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY g OTHER TYPE OF INDEMNITY 0 BOND ❑
OWNER'S INSURANCE WAVER 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 all plumbing work and Installations performed under the permit issued for this application will be lr
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER M E ,1940//1 f 4c(( SIGNATURE ,?t 1t 1 /tel ell
UC#N9f47 MPZ JP CORPORATION 2# 3Z39 PARTNERSHIP 0# LLC 0#
COMPANY NAME.W.04717,47-/re ADDRESS >///'Nt?7
CITY`iLcrcoirtaa STATE H4 wO?2 3 EMAI ice/Jiil�,S7r°oo?. 4a,
TEL U GELL770,S-n`/ FAX
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