HomeMy WebLinkAboutP-19-3227 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY 5• Y -& MA DATE I iJi 7// PERMIT#I. P-19-
JOBSITE ADDRESS .z 1 . c. 1- kid j. L.d.y OWNER'S NAME D bh e M c-mb/ e"
P OWNER ADDRESS 14 M t TEL fog-.23 C76'1 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDU TIONAL ❑ RESIDENTIAL[y'
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO 0
FIXTURES'1 FLOOR-+ BSM 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) 110:
_
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER . •
INSURANCE COVERAGE: /
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES C9' NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POUCY 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.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information[have submitted or entered regarding this application are and a to the best of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be In nce Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME ,� UCENSE# joIS SIGNATURE
MP/a, #JP❑ CORPORATION 11i ;CI 4, PARTNERSHIP❑# LLC(]#
COMPANY NAME 6t4 p G CO'CQ SR-eCL'- he ADDRESS 48 J "/Ji ,a-vi Pc'e,
CITY S VtArrAi kith STATEiN411 ZIP U tv TEL .57. ` 3cV-Z0
FAX 5m -3ty 5'75 7if CELL 546 qfp V jaj. EMAIL 571f t,9.fC C CO/24