HomeMy WebLinkAboutP-13-778 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
rs) CITY lri. 1 dent- 'iGXC+i�`l, /' Mk DATE 5-r4- f 3 APERMIT#___/9// J777
I JOBSITE A@DRESS 7 fz2G)C /2 4 /Q-,...e OWNERS NAME N/Q MOs ,...L-ThtPK-
a IO'. P OWNER ADDRESS 7 /��ar/G ice!! face TEL FAX
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(fit TYPE OR OCCUPANCY TYPE: COMMERCIAL ID EDUCATIONAL 0 RESIDENTIAL 0
PRINT NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES❑ NO 0
Gif CLEARLY Of
rf{ G FIXTURES 1 FLOOR-. BSMT 1 2 3 I 4 5 6 7 8 9 10 11 12 13 14
Y BATHTUB I - I
CROSS CONNECTION DEVICE I
DEDICATED SPECIAL WASTE SYS I I
DEDICATED GAS/OIL/SAND SYS
DEDICATED GREASE SYS
DEDICATD GRAY WATER SYS
DEDICATED WATER RECYCLE SYS
DRINKING FOUNTAIN
DISHWASHER
FOOD DISPOSER I I
FLOOR/AREA DRAIN I _
INTERCEPTOR(INTERIOR)
KITCHEN SINK I I
LAVATORY- I I • I I-
ROOF DRAIN--
SHOWER STALL
SERVICEIMOPSINK
TOILET I '
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
• INSURANCE COVERAGE:I la
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have a current liability Insurance policy or its substantial equivalent which,meets the requirements of MGL Ch.142. Yes L% No 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY / 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 BOX ONLY: OWNER ❑ AGENT 0
Signature of Owner or Owner's Agent
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 it Issued for this application will be In
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and C 142 oft the General a s.
PLUMBER NAME R"cs W/n�a�• SIGNATURE 61- C.—
LIC 4
i .LIC# 32593 NIP 0 JP Pr CORPORATION ❑# PARTNERSHIP 0 f LLC ❑#
COMPANY NAME ADDRESS: 7 Black Mai fasti— _
my /g• rer-stOG aik- STATE /02 ZIP ea66c EMAIL
TEL CELL 558 get,37ft FAxrn-i, •
pll MAY 1 4 2013 U
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ROUGH PLUMBING INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
R6#— fl /0//0-1 Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT#
PLAN REVIEW NOTES