HomeMy WebLinkAboutP-19-2635 •
air/4,000
MASSACHUSETTSS � UNIFORMNIAPPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY / 44(%17A MA DATE Y�r/v PERMIITT# filen /�/!`00�Ga%
JOBSITE ADDRESS l� C_ii2� Ttx QU i OWNER'S NAME >�//iz��✓
POWNER ADDRESS ,�yr`ie- TEVv 367 FAX -----'
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIALl
PRINT
CLEARLY NEW:❑ RENOVATION:NI REPLACEMENT:0 PLANS SUBMITTED: YES 0 NOR
FIXTURES I. 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 F C' El �V
______
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER T 3. 2818
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) 3UILDNUU_AAtt trv1 —
KITCHEN SINK 3y
LAVATORY /
ROOF DRAIN
SHOWER STALL
•
SERVICE I MOP SINK
TOILET ' /
URINAL
i 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 W2I NO 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POUCY OTHER TYPE OF INDEMNITY ❑ BOND [7�
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
' CHECK ONE ONLY: OWNER 0 AGENT 0
SC SIGNATURE OF OWNER OR AGENT
LU I hereby certify that all of the details and information I have submitted or entered regarding this application area , accurate to the best of my knowledge I
and that all plumbing work and Installations performed under the permit issued for this application will be In /• 2
f.1�.th all Pertinent provision of the 11
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /�y 7/
LICENSE f
PLUMBER'S NAME�(�7T i241/9fUt'2 , SIGNATURE
MP❑ JP[;81
nr /�f CORPORATION❑# PARTNERSHIP 0# LW 0#
COMPANY�NAA�M/EE j-e- r2v4x/ �,� ADDRESS//,oa /O �j� /gyp
CITY/N�'/�t l�T//VS A ( STATE&g_. ZIP �Y2U c'8 �/�/ TEL as/ Z2 t? /C/
FAX -�� CELL EMAIL J 2 /2 ccc. vs
tCIG (j/30 1 ° G2li
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No s
n V/ # THIS APPLICATION SERVES AS THE PERMIT 0 0 / '
• NH/rFEE: $ PERMIT It ' _ dears
. 4
PLAN REVIEW NOTES
•W