HomeMy WebLinkAboutP-14-079 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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• CITY O!'NAeta///'t / MA DATE y-5--73 PERMIT# PH 671
JOBSrTE ADDRESS /Y /iAt/�J/C aiEi f� d/ 1 OWNER'S NAME htfrmM/r Ahoe/S'
P OWNER ADDRESS /7Jair 1144r/JJ.1' 4/ji "- TEL, D1_Vsnep/I/_ S-FAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL f
• PRINT
NEW:0 RENOVATION: REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
AR
CLEEARLY
FIXTURES 2 FLOOR BSMT 11 2 I 3 4 5 5 I 7 8 1 9 10 11 I 12 I 13 I 14
BATHTUB I I I J , I
CROSS CONNECTION DEVICE I I I I _..
DEDICATED SPECIAL WASTE SYS I I I
DEDICATED GAS/01USANDSYS _ I I_
DEDICATED GREASE SYS I 1 _
DEDICATD GRAY WATER SYS I I
DEDICATED WATER RECYCLE SYS I I I I
DRINKING FOUNTAIN I I -
DISHWASHER I I
FOOD DISPOSER I I I I I I
FLOOR/AREA DRAIN _I I I I
INTERCEPTOR(INTERIOR) I I I I
KITCHEN SINK I I I I I I I
LAVATORY I i I •
r
ROOF DRAIN - _
SHOWER STALL
SERVICE/MOP SINK •
TOILET 4 I I
URINAL
WASHING MACHINE CONNECTION I
WATER HEATER ALL TYPES /
WATER PIPING
OTHER I I I
I I I I
• INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which,meets the requirements of MGL Ch.142. Yes A No❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY pli OTHER TYPE OF INDEMNITY ❑ BOND ❑
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 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 Issue for this application will be in
compliance with all Pertinent provision of the Massachusetts State Numbing Code and Cha 142 eneral Laws. -
PLUMBER NAMEnjr rr V 5 0 t! - • SIGNATURE
UC# /i 2 2 U/ MP[g, JP❑ /CORPORATION ❑# PARTNERSHIP ❑# LW ❑#
COMPANY NAME ft.r� (96/49 et !�f(/N fY�Oak/jADDRESS: `5 f i/2 (5-iL
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CITY 0( ,sSTATE�� ZIP /')/ji Y EMAIL _ a ie . .-. t.� _ - a' / . /� A
TEL f -.. _4:2 _,..a.5- CELL 5a4.4 - •
RCEIVE a
le,AUG 5201
BUILDING mi=ni
By:
I ROUGH PLUMBING INSPECTION NOTES ThINSPECTION US PAGE FOR INSPECTOR USE ONLY FINAL NOTES
_no V s—MV 7 9a1 -- .
• Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
PEE: $ PERMIT IF
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PLAN REVIEW NOTES
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