HomeMy WebLinkAboutBldg-19-007130 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
-we- CITY >IA✓KM/2(/711 MA. DATE 6—/7r /3 PERMIT# IL Yy 1$-ee 7V J
J•BSITE ADDRESS I Wl.1L 4/1X.16 OWNER'S NAME X SG/ff
06.. 1WNERADDRESS • TEL FAX
•RR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑
PRINT NEW:❑ RENOVATION:❑ REPLACEMENT: l' PLANS SUBMITTED: YES ❑ NO ❑
CLEARLY
FIXTURES 7 FLOOR-, BSMT 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB _ ,
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYS
DEDICATED GAS/OIL/SAND SYS - _
DEDICATED GREASE SYS
DEDICATD GRAY WATER SYS
DEDICATED WATER RECYCLE SYS
DRINKING FOUNTAIN - - .
DISHWASHER ,
FOOD DISPOSER _ ._.__. ...o______ .
FLOOR/AREA DRAIN • > / ' 1 +. a r ,,-;
INTERCEPTOR(INTERIOR)
KITCHEN SINK _
LAVATORY _ JIJN 8 2C19.
ROOF DRAIN _ i a
SHOWER STALL �"_ (
SERVICE/MOP SINK
TOILET
URINAL _
WASHING MACHINE CONNECTION _
WATER HEATER ALL TYPES _
WATER PIPING -
OTHER •
rs S Ud y s.6-t- _
• 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 INDICATE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY El - 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 El AGENT ❑
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 the
best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in
compliance with 11 Pertinent provi ion of the Massachusetts State Plumbing Code and C ter 142 of t Gene I Laws. F
PLUMBER NAME it./i. ` �/ SIGNATURE flei--
LIC# 1!b!v 2 MP❑ JP❑ CORPORATION ❑# PARTNERSHIP ❑# _ LLC ❑#
COMPANY NAME D ' ' C 1''h/`ADDRESS: ( O
�NJ J r Fes''O/SC /9j r :
CITY 4-/` & h 4 STATE /0 ZIP 6(7 EMAIL � Y�K /�f ereZ C /7'r`/E'er
TEL CELL 77 ;3S3 ra We-- FAX
• C, 0: 0L-1 to
__Er .CO
\V \
c)