HomeMy WebLinkAboutP-14-446 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
cm, 'Wes7 rh- Adz/ WA DATE 1147 /1C/j PERMIT# Pq— / 6
JoesITEADDRESS c .. 444c g �t�- OWNERSNANIE arcc1✓ Itch cont
P OWNER ADDRESS 3� TEL FAX
TYPE OR OCCUPANC TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDBITIAL LTJ
PRINT NEW: RENOVATION:❑ PELACEMENT:❑ PLANS SUBMITTED: YES NO 0
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FIXTURES1. FLOOR-* JBSMTI1 I 2 13 14 5 I B I 7 I B I 9 I 10 11 I 12 I 13 I 14
BATHTUB I I I I
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYS I I I I
DEDICATED GAS/DIUSAND SYS I I I I I
DEDICATED GREASE SYS I I
DEDICATD GRAY WATER 5Y5 I
DEDICATED WATER RECYCLE SYS I I I
DRINKING FOUNTAIN I I I I
DISHWASHER I I I I_
FOOD DISPOSER I I I
IOOR/AREA DRAIN
NTERCEPTOR(INTERIOR)
KITCHEN SINK I I I I I I
LAVATORY..-. I I I
ROOF DRAIN-
SHOWER STALL I I I I
SERVICE/MOP SINK • I I I I I
TOILET I I
URINAL
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WASHING MACHINECONNECTION I I I I I I
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. INSURANCE COVERAGE:
1 1) ,v 4, .: 1.,BNn,-a Ice policy or its substantial equivalent which,meets the requirements of MGL Ch.142. Yes Er No❑
" " ' r� . E INDICA THE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [/ OTHER TYPE OF INDEMNITY 0 BOND ❑
OWNER'S INSURANCE WANERZ 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 Pe hent provision of the Massachusetts State Plumbing Code and Chapter 142 of the Gen Laws.
PLUMBER NNE '<ur L. Wi! o i✓ SIGNATURE i G�
UG# d y 3 3 gp MP❑ JP / CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME 001, 5 c/Gw,hh4J /ica7f4S ADDRESS: J'ro L4/t RD
CITY we$7 Y f w•ou)k STATE Mfr ZIP 0 J4 73 BdAIL
TEL 77fr 3C3 5-4y71 CELL FAX
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nvenr('TTON NOTES
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ROUGH PLUMBING INSPECTION NOTES TILTS PAGE POR TNSPEcFOR UST ONLY
• Yee No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT
PLAN REVIEW NOTES
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