HomeMy WebLinkAboutBLDG-17-000942 h'I G, P ' • 9crc � 1
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO-PERFORM PLUMBING WORK
VW); CITY 1 ACCN �) \ MA DATE �\�� ��[J PERMIT# /54/n5"—/7-4'41 r7I97•
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JOBSITE ADDRESS \C\P OWNER'S NAME NkOur.
OWNER ADDRESS �i���=J� \�'c \
(`��Cx� L c
TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
,'LEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:Ck, PLANS SUBMITTED: YES ❑ NO❑
)(TURES Z FLOOR BSM 1 2 3 4 5 6 7 8 9 1.0 '71 12 13 14
ITHTUB
ROSS CONNECTION DEVICE- .
EDICATED SPECIAL WASTE SYSTEM
EDICATED GAS/OIL/SAND SYSTEM
EDICATED GREASE SYSTEM
EDICATED GRAY WATER SYSTEM
EDICATED WATER RECYCLE SYSTEM •
ISHWASHER
1RINKING FOUNTAIN
DOD DISPOSER -
TOOR/AREA DRAIN
NTERCEPTOR(INTERIOR) • -
:ITCHEN SINK •
AVATORY •
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ROOF DRAIN . •
SHOWER STALL
SERVICE/MOP SINK
TOILET
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URINAL • • - •
WASHING MACHINE CONNECTION
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. YES I NO.❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
- LIABILITY INSURANCE POLICY 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 aPElicabon 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 compile ith all Pet provision.f the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME C c r I 5' f ed e I I LICENSE# `� 1`y( SI IATURE -
MP\ JP❑ CORPORATION ❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME Car 1 F. • R ed e f I -r Son ADDRESS —77 i"I c,i r, S t r e
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CITY O5 ' i n e • STATE M A ZIP O a Co 5 S TEL Spa' 1--i - Co 3Cn'5
FAX CELL EMAIL C C4-fi/,.P,C/A /G CK4, -