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HomeMy WebLinkAboutMiscellaneous - Exception (215)1, ( MASSACHUSETTS UNIFORM. APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY r MA DATE Z10 1 S_( PERMIT# 6� Z- JOBSITE ADDRESS OWNER'S NAMEa?' POWNER ADDRESS t) fr TEL —IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL QJ EDUCATIONAL El RESIDENTIALZ PRINT CLEARLY NEW: RENOVATION: ® REPLACEMENT: PLANS SUBMITTED: YES © NOF FIXTURES 'l FLOOR--> 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 I , 1 I f --JI (— I__1 __ _[ __ _[ ._. -f I ! DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM^_) DISHWASHER (_[ ____ J __J .___.� .-_-_ I ___) DRINKING FOUNTAIN FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN. SHOWER STALL_ SERVICE / MOP SINK _ _I _. _.[ ..___[ _ I TQILET URINAL 'd, �SHING MACHINE CONNECTION VVA 1 tK HtA I tK ALL I YNLS WATER PIPING OTHER INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESPNO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY D BOND Q 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„ ONE ONLY: SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this ap ication are true an acc ra o the be'skn I. and that all plumbing work and installations performed under the permit issued for this application wil a li erti a rovisi the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAE t e t I LICENSE # C• G SI NATURE IVIP� JP 0 CORPORATION M]#=PARTNERSHIPLLCM#) _ j� COMPANY NAM15LI=- VA- ADDRESS CITY STATE —� ZIP TEL FAX _ CELL ��� EMAIL��r�l o z w� W ui LU LL