HomeMy WebLinkAboutWater Piping plb. permit •
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MASSACHUSETTS( UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING# WORK
'� MA DATE /Q_�! - �' ) PERMrr
06 2RFIT AD RESS 1/7(7 Ai f-"rn OWNER'S NAME �Yt�y��
Buii_ fit'; WN AD RESS �,� J�Y�° J z� TEL J `) ' 7»�/ 5`7`iRX'
Y-
--- - A MENT
TYPE Y TYPE COMMERCIAL( EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO
FIXTURES 1 FLOOR-4 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 I AREA DRAIN
INTERCEPTOR(INTERIOR) -
KITCHEN SINK
LAVATORY 1
•
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. YEJ NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY 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
1 Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT ❑
Z SIGNATURE OF OWNER OR AGENT
I I hereby certify that all of the details and information I have submitted or entered regarding this application are true an. accurate to the best of my kn• -._.e
and that all plumbing work and installations performed under the permit issued for this application will be in •mph••;,"-•.- ; • .LP; 'nen •rovision y/
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME IV((27' re(r, /i/ LICENSE# Cr] ba V ATURE
MP JP 0 CORPORATION 0# PARTNERS, IP❑.# LLC
COMPANY NAME ADDRESS /0 O buctly
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CITY i'l.�(� S��TA,,,TE ZIP ���5�� TEL 5y I5d 0
FAX CELL 7.2 1 O 6 d EMAIL 4&7? ��S f
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