HomeMy WebLinkAboutP-14-145 J . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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` ,l Cf TY yaPr,6v h MA DATE t-aq- 13 PERMIT# PI - 'v
JOBSIFE ADDRESS IT' to r icc`S IA-. OWNER'S NAME 00-0°1-$.41— //ec4/7
POWNER ADDRESS N• Iw SQ4 TEL FAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL E "'
PRINT
CLEARLY NEW:E/' RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
FIXTURESI FLOORS BSMT 11 I 2 314 5 I 6 I 7 I 8 1 9 I 10 I 11 12 13 I 14
BATHTUB I I I I I I
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYS I I I I I -
DEDICATED GAS/OIUSAND SYSI 1_I
DEDICATED GREASE SYS I I I I I I
DEDICATD GRAY WATER SYS I I I I I I
DEDICATED WATER RECYCLE SYS I I I I I
DRINKING FOUNTAIN
DISHWASHER I I I I
FOOD DISPOSER I I I I I I I
FLOOR/AREA DRAIN I I I I I I I I
INTERCEPTOR(INTERIOR) I I I I I I
KITCHEN SINK
LAVATORY-. . I
ROOF DRAIN"-
SHOWER STALL I I I -
SERVICE/MOP SINK • I I I I I _
TOILET I I I
URINAL - I I
WASHING MACHINE CONNECTION I I I I
WATER HEATER ALL TYPES
WATER PIPING I I I
OTHER - 16C€saJ lea b&okI - / I
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Z INSURANCE COVERAGE:
LJ I ha e a •urrent liability Insurance policy or its substantial equivalent which,meets the requirements of MGL Ch.142. Yes[YIN*0
r1 IF !U, NECKED YES, PLEASE INDICATETHETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LU6hci - `\ - =ILITY INSURANCE POLICY Ly OTHER TYPE OF INDEMNITY 0 BOND ❑
M �ti_ I
V � OwwNN -'S INSURANCE WAIVER: am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
L!i� Q Mt( s� husetts General Laws,and that my signature on this permit application waives this requirement
!� ` JR CHECK ONE BOX ONLY: OWNER 0 AGENT 0 •
S'•n_ tire 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 permit issued for this application will be in
compliance with all Pertinenttiprovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER NAME Te `nett`y Riczcd SIGNATURE
LIC# /3.2 5-6 MP II/JP❑ CORPORATION 3/6 V PARTNERSHIPAR ❑4 LLC ❑#
COMPANY/NAME `I 1.0-d- plc/Ash tcj '`E- ADDRESS: / 5. recti�/ ' •
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CITY aAsve- - STATEe#h ZIP o2330 EMAIL.(7.404.61))47/(€.0-4b, ctiG 4. WSi1f-, .1-j'
TEL2 %C 3.201 CELL 9r we. yam( FAX /COX n/ 3201(
iNSPECTiON
L ROUGH PLUMBING INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL NOTES
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Yes No r-" t /�G
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT#
PLAN REVIEW NOTES