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HomeMy WebLinkAboutP-19-435 • 4 - • MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM PLUMBING WORK L ' CITY_10A-0101-4-4 MA DATE 7', DU� 1,477 PERMIT# I I't"nt' y_/ ,s JOBSITEADDRESS a 4 Foul St a.SOAJ3 We OWNERS NAME fr of we' POWNER ADDRESS 190 }J. At fr' Scl- TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL lir-- PRINT i"PRINT CLEARLY NEW:©-- RENOVATION:0 REPLACEMENT:❑' PLANS SUBMffTED: YES 0 NO 0 FIXTURES 1 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 - DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM U DISHWASHER ih DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN ___._ _ _ - INTERCEPTOR(INTERIOR) i irk__r c+ f ! t I= o I KITCHEN SINK t I ' I.� — - - - -- i ILAVATORY 3, / I ! I �r ROOF DRAIN } I JI ti 1 9 / l ltl I SHOWER STALL I /.• - I I SERVICE I MDP SINK .. '/ } � I TOILET �' / I .,. (-•:116 .- c- - j I, I URINAL . vi WASHING MACHINE CONNECTION /.. tt 1 WATER HEATER ALL TYPES / 11 I WATER PIPING ] OTHER -;tc ; at}:C4.1 \ . INSURANCE COVERAGE: -b i I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES' NO ❑ v IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY [ OTHER TYPEOF 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 I Massachusetts General Laws,and that my signature on this permit apilication waives this requirement •'' CHECK ONE ONLY: OWNER 0 AGENT 0 4- 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 larowledge and that all plumbing work and Installations performed under the permit issued for this application will be In compOance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME -ally RC0-Gd0 LICENSE# iVS'6. SIGNATURE MP Er JP 0 nn 1 CORPORATION Elf3iSy PARTNERSHIP # v ' LLC❑# COMPANY NAME Y GI /VMbttit3 -�VC. ADDRESS S3� •Jam"^ FU`'ac-G Rd. CITY 91 y�i U., STATE 044 ZIP Cl4:�6o TEL 7 t 223 7460 FAX CELL WI. SV6 4'S'S•1 EMAIL c_12/ abb— ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No 2 !J J C THIS APPLICATION SERVES AS THE PERMIT D ❑ i) �I L/,v n- / 1 (` Z 4 1/ 7/f /f FEE: $ PERMIT# V 2 c7/�""'��C /e a C PLAN REVIEW NOTES 4) ill° /i 2 $i/eCecc. n/ift