HomeMy WebLinkAboutP-17-2332 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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PERMIT# /%1�P"/7�Da�3
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JOBS E ADDRESS 61 ai-re- Pb . OWNER'S NAME Are
OWNER'S e77
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL 0 RESIDENTIAL
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
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/01L/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM _ •
DEDICATED WATER RECYCLE SYSTEM
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A DRRINKINGKING FOUNTAIN `
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
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LAVATORY \\\\ r
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES®'ANO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY ®— 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
J Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
t11 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 Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Q,
PLUMBER'S NAME 27!/9.--"/1
LICENSE#7r/-4�� SIGNAL
MP tMP Er JP 0 CORPORATION ,197 I' PARTNERSHIP 0.# LLC 0#
COMPANY NAME_ 47/..O/i7//#i/4"-- c ADDRESS // ede1,A _r
CITY G✓ �j� re a rr,C E I V F, STATE /',4 ZIP c:5376--7-f.CELL
FAX !/ MK 01 ELL 174Tp 'o7EY EMAIL Irfilril-! �/»(057t • 0"-"
BUILDING D ray . ' / �
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
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THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
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