HomeMy WebLinkAboutP-12-689 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
ra iso CITY )012/00(17711- MA. DATE 6,40/174Z PERMIT rit 60
JOBSITE ADDRESS l‘ /Win 5:S9gdS 090 IVr SY. OWNER'S NAME 6442,Y P.01/61//rcrN27.2
p OWNER ADDRESS /S 4,cceLOW STAs7 r 0kr-0,1,0CTTEL 5 &fl-DB97 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL IN-
PRINT NEW:❑ RENOVATION:0 REPLACEMENT:®' PLANS SUBMITTED: YES❑ NO ®-
CLEARLY
FIXTURES 1 FLOOR- BSMT 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE I R ! •
DEDICATED SPECIAL WASTE SYS
DEDICATED GAS/OIL/SAND SYS
DEDICATED GREASE SYS ' 11.2 1:2,;01:1,9
DEDICATD GRAY WATER SYS
DEDICATED WATER RECYCLE SYS I 1,DRTENT
DRINKING FOUNTAIN BU LD
DISHWASHER • --• ''
FOOD DISPOSER
FLOOR/AREA DRAIN (
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN _
SHOWER STALL
SERVICE/MOP SINK _
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES l
WATER PIPING
OTHER '1'
it 4ek•
INSURANCE COVERAGE:
i have a current liability Insurance policy or its substantial equivalent which,meets the requirements of MGL Ch.142. 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BEL _
• LIABILITY INSURANCE POLICY t71 OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:1 am aware that the licensee does not have the insurance coverage required by Chapter 14 f 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 Pertinent pro/visio/n/oofy/of the Massachusetts State Plumbing Code and Chi er 142 of the Gene .I Laws. •
PLUMBER NAME �-.�' ' r`is,4 _ se SIGNATURE lir / 1 ne
O /
LIC# d 0. /y,,r!MP,�-... JP❑ CORPORATION C'# g S1 PARTNERSHIP 0# LLC ❑#
COMPANY NAME ./f /* yr-AC ADDRESS: Ye(i Ol-/J O</1n-thstSH ,Qzt
CITY &)07/r nenn,5 STATE mn ZIP 666 EMAIL / ////-Va >. re/6 t :We ef/e
TEL 507-3U-7/177 CELL FAX tfOcf-083=64 0 y-
Y
ROUGH PLUMBING INSPECTION NOTES TillS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES