HomeMy WebLinkAboutP-18-5999 i -1r inAP: PAR Ct C :
, ., MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �g�
. �— ' � MA.DATEP4\�'A'SC IPERMIT# /9//7-cvF s
1.-et- CITY ��m
JOBSITE ADDRESS K) (e Si!91„wt Ps-&-R- ' I OWNER'S NAME fi 1 e t W. I
P ,OWNER ADDRESS h-et ...-f- I-•-kc 's p p rc• ,/--AA • I TEL J CR-3-4,-ra AX
TYPE OR OCCUPANCY TYPE COMMERCIAL El ` EDUCATIONAL D RESIDENTIAL •
PRINT
CLEARLY NEW:D RENOVATION:CT REPLACEMENT:D PLANS SUBMITTED: YES 0 NOD
FIXTURES 7 FLOOR-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 IT 14
BATHTUB _ -� , �
CROSS CONNECTION DEVICE l 1 S immai
DEDICATED SPECIAL WASTE SYSTEM IflS� ;
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DEDICATED GAS/OIUSAND SYSTEM '�
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DEDICATED GREASE SYSTEM .r S "'�1 _n
DEDICATED GRAY WATER SYSTEM1 _ _ 1 � P
DEDICATED WATER RECYCLE SYSTEM i
DISHWASHER �i - '
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DRINKING FOUNTANn �I ,fes
FOOD DISPOSER 1 r r10• 111-1111111111111,11Ji SIS
FLOOR I AREA DRAIN 1 'c
INTERCEPTOR I "IQR " Iccee _,1 ,Il lb 1
KITCHEN SINK — c-+ t . _ I ._ , _
LTJ 1 cif t ., 11i
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SHOWER STALL I I ��._,iii * —
LAVATORY
ROOF DRAIN r ) c e
SERVICE J MOP SIN S -1I J i—i_l IS' ' TE
TOILET L. - in ism?ims: ss .s
URINALASH �j flSf I�.I
WATER HEATER ALL TYPES IS S
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WASHING MACHINE CONNECTION ��L�i�'i
WATER PIPING Mt ASS= lal 'Mail 7
OTHERMI it j�
• INSURANCE COVERAGE: ,�../
I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES D NO Uv
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY D OTHER TYPE OF INDEMNITY 0 BOND D •
OWNER'S INSURANCE W•i .' ware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Massachusetts General .•• at my signature on this permit application waives this requirement
a, CHECK ONE ONLY: OWNER EI AGENT ❑
SIGNA -r.WNERORAGENT '
I hereby certify that all o • = de •s end Information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing • -•• •-nations performed under the permit issued for this application will be In with all P 'neat provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME j,11$Cf : L lin• I IJCENSE#13n3r1 SIGNATURE - /42
MPD JPEr CORPORATION DO ' IPARTNERSHIPO# LLC[3# - I
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COMPANY NAME RAs,-,A C6I,kJ I ADDRESS 2,6 CGW A;n 631ovind Raz I
CITY!500h Warine'1 I STATE VIVI1 IJP OZGGL/ ( TEL S&Z LI c.-LCj.42 I
FAX CELL I EMAIL /r�SMCrtIrr'l ctra We rN ran. I
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ JJ� /J
FEE: $ PERMIT#
PLAN REVIEW NOTES
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