HomeMy WebLinkAboutP-19-5846 ('Fr it.sT
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY V//g{+/6 Tn CJ72_T MA DATE if// (t? PERMIT#�1PP71 Od S-596
JOBSITE ADDRESS 96 /347.uptde1C i Q OWNER'S NAME PiifR6-Ed/ 5
OWNER ADDRESS S /11 TEL 7176`fs/S 4146 y7X
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL'
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CLEARLY NEW:ig RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMI I I ED: YES❑ NO
FIXTURES 7. FLOOR--F BSIv1 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
_ KITCHEN SINK '.' »:: a;
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET I, <t. ii Q
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417
URINAL
WASHING MACHINE CONNECTION
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WATER HEATER ALL TYPES /
WATER PIPING
OTHER
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YE$ 'NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY lg. OTHER TYPE OF INDEMNITY ❑ 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.
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CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR 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 in co liance with all P me t ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# SIGNATURE
MP ❑ JP CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME e Er 5 /i3 6/0 ADDRESS 2&c ze P R
CITY /C>T1 IJl/f / STATE 14 if ZIP oA6 3 a TEL S197,0
FAX CELL.SO$ t( 9`6d5- EMAIL
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