HomeMy WebLinkAboutP-19-2895 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
=_I_r • CITY 7a..renot. 4 k ( MA DATE tt"t . Za 1V PERMIT# l /�� i7C) We
JOBSITE ADDRESS W' Bretz—1 PT t`-JZ OWNER'S NAME ENS 1 SJ Zane C-
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIALW
PRINT
CLEARLY NEW:0 RENOVATION:[K REPLACEMENT:0' PLANS SUBMITTED: YES 0 NO 0
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 6 9 10 11 12 13 14—
BATHTUB
CROSS CONNECTION DEVICE .
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM J
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM .
DISHWASHER 1 •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY I .
ROOF DRAIN
SHOWER STALL
• SERVICE I MOP SINK
i TOILET
URINAL
• WASHING MACHINE CONNECTION I
WATER HEATER ALL TYPES
WATER PIPING •
OTHER
1 UL en k[Ger I
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ti4,. NO 0
IF YOU CHECKED YES, PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POUCY Vel, OTHERTYPEOF 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
1 Massachusetts General Laws,and that my signature on this permit application waives this requirement
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T CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
kkl 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 knowledge
and that all plumbing work and installations performed under the permit Issued for this application will be In compliance with all P •nent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Sean 4anre-Son LICENSE# I5flZ. SIGNATURE
MP [! JP 0 CORPORATION 0# PARTNERSHIP 0# LLC 0 it
COMPANY NAME NAfm- nu,,, Pk-(-t ADDRESS ?a cw 6&C' •
CITY Ctnlcrv`kL STATE mom' ZIP OZ632- TEL -1114_23kro2tC.
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FAX CELL EMAIL Ilan r7u r,1(g✓misTh�QA�Vn�•LLM
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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 Pr
!� _ / _ 0,P
FEE: $ PERMIT It
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PLAN REVIEW NOTES
70.1/1