HomeMy WebLinkAboutP-13-802 +� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
"a cm( 7a.-hc;Tr—-�� MA DATE] 2c fl f PERMIT it PI'r3— STIP
JO&SITE ADDRESS % C o$t tn\Y, dc‘Lei -r Q OMINERS NAVE Otsht,t
P OWNER ADDRESS S C%Mct. TELj s p% y 31co$
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL® ,
, PRINT
CLEARLY NEW:Li RENOVATION:0 REPLACEMENT:® PLANS SUBMITTED: YES LI NOMI
FIXTURES 1 FLOOR-. BSM J 1 J 2 J 3 J 4 J 5 J 6 J 7 J 8 19 J 10 11j t2 13 J 14 -
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/01LISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK + '
LAVATORY
ROOF DRAIN
SHOVER STALL '
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
+ l
INSURANCE COVERAGE
I have a anent JIaMNy lnwanos policy or Its flats equivalent which meets the mquYamsnts d MGL Ch.142. YES Q] NO LI)
E YOU OEECKEO YES,PLEASE INDICATE TIE TYPE OF COVERAGE BY O1E O1G THE APPROPRIATE BOX now
LW81Lcry INSl1RANCE POLICY IN OTHER TYPE OF mann' ❑ Bow 0
OWNERS INSURANCE WAIVER:I am aware that Aha Iris.dole net hew the Yetaanee oro rqa raqund by Chap*142 of the
Waediusstts General Laws,and that my sgnattas on this permit application Ellm this requirement.
SIGNATURE OF OWNER OR AGENT BECK ONE ONLY: OWNER [ ] AGENT Li
I hereby certify Int d d the deli and nbnr/im I true atnaad a shared regeffinV the appicedon an true and.cane to the bele d
and that ea pManbau work and rraaatln,a perkansd user Is punt btad nor his apperatlnn ell ben compllarw P,rtnsa my www
1AssasdPlumbingsts State Plumbing Cade and Chapter 142 dine Gas Leas. IM M my
d the
PLUNDER'SME�\roZ.
NAtyrtt-V. c‘-)4=06-Nei Trl 'LICENSE• g6 e? SIGNATURE
'k 'F U CORPORATIONI Sl t%° \ IPARTNERSHIP0C1 Lie El' --
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COMPANY NAME'G�.`M %A to SStrow. ) 1.4 ADDRESS \ W 2A1why't% c?..6.
CITY 1_1+1L \v STATE Sit ZIP pzss6 S TEL -
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FAX ]cFa LIe1 Ras Divi i FLAT roi - , D
n� MAY 2013
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�;h,.vaV ;CEPT
ROUGH PLUMBING INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT[«
PLAN REVIEW NOTES
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