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HomeMy WebLinkAboutP-14-370 tr_, }care -t . dc� ► PO Ia4t27o57 • 1s. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK try:• _y' cm,\ icn 17-f IAA DATE 10 Q I ►� PERMIT ti_ i4-37o JOBSITE ADDRESS 181 \sr+ (Sands 1--n 1 MRS WAME Luca nSl OWNER ADDRESS I I waIe - TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTUIL,_ PRINT • CLEARLY NEW:j_] RENOVATION:❑ REPIJGEAENT:( PLANS SUBMITTED: YES Li NOLJ FIXTURES 1 FLOOR-. ISSN ' 1 J 2 j 3 j 4 J S 6 ) 7 I 8 j 9 10i 11 j 121 13 J 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/UL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISFNYASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINAL • WASHING MACHINE CONNECTION WATER HEATER ALL TYPE_.... 111111 TIER -`+ E-� Mira, ri4 p3 ©� 9 Lu I have - „NG DE INSURANCE COVERAGE: r� E,o subsistedaqulvabnt which meats the requirement*t4 lath 14 b. orfs( J No Q BY F You. . -: - PLEASE INDICATE TIE TYPE OF COVERAGE BY CIEOCAG TIE APPROPRIATE WM BELOW .1/5 LIABIthY INSURANCE POLICY® OTHER TYPE OF mean ❑ Born❑ j OWNERS INSURANCE WAIVER:I am aware that the Scans does not have the intaana coverer required by Chapter 142 of Messacttuselts General Laws,and that my'Igniting on a permit application Um this requirementCHECK SIGNATURE OF OWNER OR AGENT ONE ONLY: OIMNER _] AGENT j I hefty candy that w at M owes and inky tenon I In r6mitted or rued rsprciMp this-n.-&aloe at hue and accurate to Its her d my kmseype and that al plumbing Bork and krfadtSa performed older We permit head bar Inie aWaraaLB ell be In with el Pertinent Mauad s State Pkmhkg Code and Chapter 142 d the General Late. 1 d the PLUMBER'S NAME \'rokertt-k '(11 ax�c,rn 'LKENsE#I(zt, SIGNATURE lak 2LJ CORPORATION ?%c\C\ PARTNERSHIP❑Nf �LLCLJ# _...__..._..I E COMPANY NAM _. ME Cz M � l tw rn� t r e C• tr tt.e s `w ADDRESS( \ W 2`‘t n liter , R� ► CITY L.\el c�n 'STATE ZIP Ov G TEL 1 I Li C. cis � FAX ICELLILi0lb3ti'1ViiEIJAILI --- -- "' —► ROUGH PLUMBING INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES ti Yes No THIS APPLICATION SERVES AS THE PERMIT 0 ❑ 4 FEE: $ PERMIT# PLAN REVIEW NOTES R 4