HomeMy WebLinkAboutP-19-3461 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
-L� CITY Sou-{4n YL-Ir'0i-rth MA DATE Z GI le& PERMIT# r'i�w0-4:2'a✓*/W
JOBSITE ADDRESS \ Gc.ICo. OWNER'S NAME •
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL
PRINT }
CLEARLY NEW:❑ RENOVATION:(N REPLACEMENT:❑' PLANS SUBMITTED: YES 0 NOl .
FIXTURES 7 FLOOR-+ BMA 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
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER •
DRINKING FOUNTAIN
FOOD DISPOSER _
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) r---
KITCHEN SINK J \ i`' C. L _ t4
LAVATORY
ROOF DRAIN j]
J
SHOWER STALL r G-C () 2n1.
• SERVICE 1 MOP SINK 1 1 I 1
TOILET buiLDlfJGO( -�),is ' i Tr
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 NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY OTHER TYPE OF 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
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
L:I I hereby certify that all of the details and information I have submitted or entered regarding this application are tnie 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 Ge-a.r+ kart rcina-n LICENSE# eta SIGNATURE
MP JP❑ CORPORATION 0# PARTNERSHIP Q# LLC❑#
COMPANY NAME 1"14 l rr P+1-k ADDRESS Q!) eo y bele
CITY GGri f of J'�U� STATE 01 ill— ZIP 02452 TEL 774rZgp4zSCo
FAX CELL EMAIL 14l1 rk 4rcrt umb,;NI6.- A-C(..conk
IF to CC e
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT# /tO ' '� /9)41
PLAN REVIEW NOTES --
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