HomeMy WebLinkAboutP-13-804 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CTYStea(Jn/ YCQ(/P�In MA DATE 5/22/i'5 /�.PERIrv11T#J/3 Gt/7
JOBSITE ADDRESS (90 rZZ/rL)Od OWNERS NAME (fta Onccj
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE: COCIAL❑ EDUCATIONAL RESIDENTIAL
PRINT
IA •RLY NEW:0 RENOVATION: REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO ❑MM
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6^ FIXTU a:S 2 FLOOR—, BSMT 11 12 l 3 4 1 5 6 I 7 8 I 9 I 10 I 11 I 12 I 13 I 14
cm BATHT B
N- o CROS•.CONNECTION DEVICE I
DEDICATED SPECIAL WASTE SYS I I fI HT
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, n DEDICATED GAS/OIUSAND SYS I I l f
cri y DEDICATED GREASE SYS
r ;Sr_DEDICA D GRAY WATER SYS I I I
DEDICATED WATER RECYCLE SYS I I I I
Ca DRINKING FOUNTAIN I I
`DISHWASHER I /
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FOOD DISPOSER I I I I I
FLOOR/AREA DRAIN I I I I
INTERCEPTOR(INTERIOR) I
KITCHEN SINK
LAVATORY
ROOF DRAIN"'
SHOWER STALL / .
SERVICE I MOP SINK I
TOILET 1 I I I I I •
URINAL I I
WASHING MACHINE CONNECTION l
WATER HEATER ALL TYPES I
WATER PIPING / I
OTHER I
• INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which,meets the requirements of MGL Ch.142. Yes 0 No❑
IF YOU CHECKED 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 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 Pertinen rovision of the Massachusetts State Plumbing Code and h pter 1 e General Laws.
PLUMBER/ NAME 14AAJ vat rk • SIGNATURE
LIC# ! I l�I.z MP fr JP❑ /' CORP RATION # 5r�i PARTNERSHri❑# LLC ❑#
COMPANY NAME L� ��/ ADDRESS: 37 ��I �T/]
CITY L tient STATE/✓tAI ZIP (9'?65ZEMAIL•
TEL S fl Z C) P176 S CELL FAX
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ROUGH PLUMBING INSPECTION NOTES TIUS PAGE FOR INSPECTOR USE ONLY
FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT II
PLAN REVIEW NOTES
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