HomeMy WebLinkAboutP-19-2993 •
620
N., 7' MASSACHUSETTS UNIFORM APPLICATION FOR A ERMIT TO PERFORM PLUMBING
,WORK
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CITY 50 ~l 1 M d tJ MA DATE /f PERMIT# /1. ,//'��wr[,
JOBSITE ADDRESS 2-o 6 L no s1-c../1 /2/1 OWNER'S NAME) n , �r A .
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OWNER ADDRESS (I50Y )TEL3 ?P7??X TELFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO 0
FUTURES 7 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 .
DISHWASHER •
DRINKING FOUNTAIN 1
FOOD DISPOSER
FLOOR f AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL E ' E U
• SERVICE I MOP SINK err n�
I TOILET I "uY L: zo IiJ
URINAL
i WASHING MACHINE CONNECTION at ILDJ nr=1111--
WATER
-
fWATER HEATER ALL TYPES ar _ MRF,,, NI
WATER PIPING
OTHER •
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESCO NO 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY _ OTHER TYPEOF 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
Massachusetts General Laws, and that my signature on this permit application waives this requirement
CHECK ONE ONLY: OWNER 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT
LAI 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 Coe and Chapter 142 of the General laws. Q J_
PLUMBER'S NAME A4 (GaE L41 4/3 rr 04' LICENSE# SIGNATURE
MP ❑ • JP N p r0 P CORPORATION❑# PARTNERSHIP 0.## LLC❑#
COMPANY NAME Vlt ( f t eke f J H.71--ADDRESS/ �
ADDRESS 9/ "J 61517 C O r/0
CITY 1 A_ �c !/VI (-A Jl'� 1 STATE ZIP O 2-G, / 3 TEL )1 Y 7/0 7I?z
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FAX CELL EMAIL
Cly 44 di (pD
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0 , r1,i/J o
S �Y i`'
FEE: $ PERMIT IF
ELAN REVIEW NOTES
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