HomeMy WebLinkAboutPlumbing Permit MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
==1_f— : CITY )/./J l/- UM * (') MA DATE / U—2 v—/ ( A441"--1 ----'PERMIT#—�. 60 'v
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• JOBSITE ADDRESS P 1 i i----eQ C OWNER'S NAME l
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POWNER ADDRESS ( l- TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑/ PLANS SUBMITTED: YES❑ NO❑
W FIXTURES-1 FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE _
DEDICATED SPECIAL WASTE SYSTEM
Z DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
j FOOD DISPOSER /e
FLOOR/AREA DRAIN A�id
INTERCEPTOR(INTERIOR) �}
KITCHEN SINK „'C,'. .' -
LAVATORY
4, ROOF DRAIN )
SHOWER STALL .,c> rA
SERVICE/MOP SINK �' G�
TOILET
URINAL
ti, WASHING MACHINE CONNECTION
1WATER HEATER ALL TYPES
WATER PIPING
OTHER
Liv, -e -I-0 S'-t?-77 / _ _ ,
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. Y _NO ❑
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IF YOU CHECKED YES,PLEASE INDICATE THE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND ❑ IV,-.V /4 2014
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Ch ter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement. HEALTH DEPT.
CHECK ONE OI�J_Y: OWNER D AGENT ElSIGNATURE OF OWNER OR AGENT /
I hereby certify that all of the details and information I have submitted or entered regarding this application ar- rue -p ecur 'to t.- best of my nowled
and that all plumbing work and installations performed under the permit issued for this application will be in�Vim. ance wit l P- -nt provis' h
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. j• ' ��
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PLUMBER'S NAME � )1vl I'l p CENSE# u6( - ' SIGNATURE
MP EjlIP❑ CORPORATION❑# PARTNE'SHIP❑# LLC I�J”(-cl))
COMPANY NAME (E 7 L / 1 cL Q E1 To r•QADDRESS / > 3 Oc.)I 7)4.-7...Q 1' C I z L it:-
CITY m ,f 2-7r`-2"C_ STATE ilii) ZIP C.7-�� "IEL56/ C 7 > - P0 V
FAX CELL EMAIL I / , ; ,