HomeMy WebLinkAboutP-19-0789 MASSAOHUSE—THS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK —
—= 3 CITY 51,,LA ` dt-K(ha4_0 ` L MA DATE PERMIT#1/ P/217-6227
JOBSITE ADDRESS Vet 1 Co-r- ii‘er✓'_ OWNER'S NAME •
POWNER ADDRESS k.—A— LJILVSc.N TELCO -2S8-o8z1AX�_
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL'S
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CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:Er PLANS SUBMITTED: YES 0 NOW
FIXTURES 7 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE fill _
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/DIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM • '
DEDICATED WATER RECYCLE SYSTEM -
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN _
INTERCEPTOR(INTERIOR) r) I= - ;` � ett t= E I - .
KITCHEN SINK 7.—A ,— 1
I
LAVATORY I 1 ' ' 1
1(0
ROOF DRAIN I tii; 0 / jOIJJ
I SHOWER STALLI
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I SERVICE IMOP SINK , ; nii rn iG DE DART ,AUNT •
I TOILET e
URINAL —- ——
/' WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
I WATER PIPING
I OTHER •
I
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO/.11r
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
i Massach s General Laws,and that my signature on this permit application waives this requirement
4-h '�e. CHECK ONE ONLY: OWNER AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this appliice'• •-true A!accurate tote best of my knowledge
and that all plumbing work and installations performed under the permit issued for this appfcation wil .i I•mpf; .- with all Pertinel provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / 'APLUMBER'S NAME & s\ ' P\__c C 1 LICENSE# 2/a36 / SIGNATURE
MP 0 • JP CORPORATION 0 it PARTNERSHIP a# \L"LC 0#
COMPANY NAME -t ADDRESS �7c� �e\d Z5 �1 �yq
CITY O"\ou)cC� STATE (Y\ v. ZIP CCA.c(o ") TEL en/ Lig)—G '2
FAX '.----� CELL c ( EMAIL p/I
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 ❑
FEE: $ PERMIT if CAV(.
PLAN REVIEW NOTES O V