HomeMy WebLinkAboutP-19-0761 •
MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
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CIN \I dI Z wcKl .� MA DATE Y'/ IAr.40/ 2C1LYI PERMIT# %!`o&7CPf
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JOBSITE ADDRESS 'S t-( ( IJ46I .4ue OWNER'S NAME Doody Q
POWNER ADDRESS 31-\ ` 4Mc TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL'g"
PRINT
CLEARLY NEW:0 RENOVATION:(2 REPLACEMENT:❑' PLANS SUBMITTED: YES 0 NO 0
FIXTURES? FLOOR-, BSM 1 2 3 4 5 6 7 8 9 1D 11 12 13 14
BATHTUB
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CROSS CONNECTION DEVICE 1 •
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/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY / •
ROOF DRAIN
SHOWER STALL A /)
SERVICE I MOP SINK (t 0l
I TOILET I „ w tr
URINAL I:
i WASHING MACHINE CONNECTIONWATER
WATER PIPINGALG ALL TYPES 2L}S
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OTHER
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YESV NO 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY INSURANCE POLICY V OTHER TYPE OF INDEMNITY ❑ BOND 0
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.
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CHECK ONE ONLY: OWNER 0 AGENT 0
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SIGNATURE OF OWNER OR AGENT
Vi I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and accurate to the best of my Imowiedge
and that all plumbing work and Installations performed under the permit Issued for this application will be In compliance with all P rent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. „ / t
PLUMBER'S NAME LICENSE#ZQO/b . 644/1.4.141.-ti
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MPD • JP CORPORATION I:1# PARTNERSHIP Q# LLC❑#
COMPANY NAME CAA 1.tLAwl t-C/.e t 130ki•4kk t 1 c4 ClearADDRESS Po &r,C dad
CITYs,cv_erjd C4-wC kJ5 STATE WA ZIP d2.Ct - TELJrog2sr- ?ow
FAX CELL SZi6-2 17-3737 EMAIL
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ROUGH PLUMBING INSPECTION NOTES ,BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
_ /4 JAIL /
FEE: $ PERMIT i
PLAN REVIEW NOTES