HomeMy WebLinkAboutP-14-254 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING
,WORK
1 CITY Y}�110(1 MA DATE /Q-/lam /3 PERMIT# PNaJ
JOBSITE ADDRESS '7/ J)ea s t/LL /21D OWNERS NAME f aiW /-CPP
POWNER ADDRESS _7,blitc. TEL FAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIALg
PRINT
CLEARLY NEW:0 RENOVATION:g REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
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FIXTURES 7 FLOOR I BSMT 11 I 2 I 3 I 4 5 6 I 7 8 19 I 18 11 I 12 I 13 I 14
BATHTUB I I I I I I I
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYS I I I I I I I I I
DEDICATED GAS/OIL/SAND SYS I I I I I
DEDICATED GREASE SYS I I
DEDICATD GRAY WATER 5YSI I I
I I
DEDICATED WATER RECYCLE SYS I I I I
DRINKING FOUNTAIN I
DISHWASHER / I I I
FOOD DISPOSER I IF 1I I
FLOOR/AREA DRAIN I I I I I
INTERCEPTOR(INTERIOR) I I I I
KITCHEN SINK I / _ I I I I I
LAVATORY
ROOF DRAIN"' I
SHOWER STALL 1 / II I I
SERVICE/MOP SINK •
TOILET I A I I I I I
URINAL I I I
WASHING MACHINE CONNEC N I I I I
WATER HEATER ALLRYPES i I I I
WATER
PIPING, `.4;1---Zi) I /
1 t[
i Cir%it 20 r -
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LENT INSURANCE COVERAGE:
I ha a 4E4IFQJ1i?U suran policy or its substantial equivalent which,meets the requirements of MGL Ch.142. Yes 0 No 0
I Y HECRED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 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 0 AGENT 0
Signature of Owner or Owners 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 Pertinent p vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER NAME 81:11.) Nei. SIGNATURE a
UC# 11l eiC MP JP❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME /w �6 -� /3(./J/U/` `� /7' ADDRESS: /9 / 6_0-yea's r% mCITY to a/9e ,7-y9- STATE/ Mit ZIP 02-66 L
TEL SDa 7-762- 83243 CELL FAX •
FINAL INSPECTION NOTES
• ROUGH PLUMBING INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY
ip Ph-o Df 1424 /B/l7/IJ Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT IF
PLAN REVIEW NOTES