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HomeMy WebLinkAboutPlumbing Permit • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK r= e'— � CITY \(ifl2MO r _� ��, MA DATE �C, I� �! PERMIT# APP-/C-00,55��� JOBSITE ADDRESS 3 Oe-e/V/L 140 } OWNER'S NAME -.tSe_f7L) F>J{-I es5-6 hi, P OWNER ADDRESS Saf. OCTA14 RUC, TEL FAX •SI.. TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL ❑ RESIDENTIAL Imo" PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:© .---- PLANS SUBMITTED: YES❑ 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/OIUSAND SYSTEM riFillU\MVP DEDICATED GREASE SYSTEM Z DEDICATED GRAY WATER SYSTEM RC11014 DEDICATED WATER RECYCLE SYSTEM _ k' DISHWASHER -HEALTH DEP!. DRINKING FOUNTAIN FOOD DISPOSER 19 FLOOR/AREA DRAIN 4 INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL �' r SERVICE/MOP SINK ` TOILET 54 L LLLURINAL WASHING MACHINE CONNECTION EC '7 <OlLi + a WATER HEATER ALL TYPES WATER PIPING a--5:-;=;,,,- , OTHER � ... Neio se-F,TIC_, I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES E NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT ❑ I hereby certify that all of the details and information I have submitted or entered regarding this application are tr a nd accurate to the pest of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in com li "th all Pe e/it provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /!� / /�.� PLUMBE 'S NAME J - c, A r / • N ` � LICENSE# 9.6:27 /ft ' SIGNATURE MP[� JP 0 CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME tL``• 414 (11i - Oki ADDRESS 11/7 1-14 J/-4O 01 CITY.! A-ki 7--I1 S . STATE i9- • ZIP C)o`Z6::>O L . TEL .c.-0 "'/( FAX CELL:ca'77t2- `Z EMAIL • (, 14-(le--!/ ,4a.COI.$ Ve( .01 Gam`- '/