HomeMy WebLinkAboutPlumbing Permit 3
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� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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�UjQ DAT� PERMIT# �DR�/5-Z">CJ -�70�
� � JOBSITE ADDRESS � 7 S� v�"Q 'S 7 �% -P I�✓� OWNER'S NAME � e � l�I "L'� ��V�'1� "/1 P �
i �' P OWNERADDRESS J7 S' l U�-P Sj� I,� �'- TEL FAX
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� TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
� CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
.� FIXTURES 7 FLOOR-+ BSM 1 2 3 4 5 6 � 8 9 1D 11 12 13 14
� BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
� DEDICATED GASIOIUSAND SYSTEM
DEDICATED GREASE SYSTEM
� DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
� DISHWASHER
� DRINKING FOUNTAIN
FOOD DISPOSER
� FLOOR/AREADRAIN —
WTERCEPTOR INTEBtOR)..
KITCHEN SINK �" "' ^ �: ;
LAVATORY _ _� . —. : ..
� �
ROOF DRAIN � �
SHOWERSTALL � j ? (�j5
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER i ✓.2 C
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WSURANCECOVERAGE:
I have a current liabili insurance policy or its substan' quivalent which meets the requirements of MGL Ch.142. YES NO ❑
IF YOU CHECKEO YES,PLEASE INDICATE THE TYP F COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHERTYPE OF INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER:I am aware tha[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 I have submittetl or errtered regarding this application tru d ac to the best y knowledge
and that all plumbing work and installations pertormetl under the permit issued for this application will be i co ance ' Pertineni sion of the�
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S fjIDAAE �1 U"I�'j�IYI�C l�J� y'�' I/ LICENSE#��Il! SI N URE
MP[� JP❑ � CORPORATION�# � PARTNERSHIP❑# LLC[��7 3
COMPANY NAME W UI�.PADDRESS I 5 � � � 4v[�'�/�I?i I `r�
CITY ��L,,l `�//✓"C "'� STATE ZIP(y �-' 7 / TE4�—/ ��o,�'>�
FAX CELL EMAIL
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