HomeMy WebLinkAboutP-14-045 •
I
y I TTS MASSACHUSEUNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
_+ CITY @ /AR l,�/A . MA. DATE'/ P-22 -/-3 PERMIT# P4a QC
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JOBSITE ADDRESS 2 U��.it/.t/ p.�'I�7 OWNERS NAME EDMtin17 �. 'P-SS/jl
POWNER ADDRESS —9.4M TEL FAX
TYPE OR OCCUPANCY WP . COMMERCIAL 0 EDUCATION 0 RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES 0 NO 0
•
FIXTURES 1 FLOOR BSMT (1 I 2 I 3 I 4 5 6171819 10111112 131 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYS I I I I I
DEDICATED GAS/01USAND SYS I f
DEDICATED GREASE SYS I I I I I
DEDICATD GRAY WATER SYS I I I I I I
DEDICATED WATER RECYCLE SYS I I _ I
DRINKING FOUNTAIN I I I I —
DISHWASHER I I +I, --.I—'—_-- . -
FOOD DISPOSER I I ' ' I t•` ¢ 1.``I I
FLOOR/AREA DRAIN I -I--'' I I
INTERCEPTOR(INTERIOR) I
KITCHEN SINK I JdL 2 I I I
LAVATORY..-_ II1 I i I
SHOWER STALL ROOF DRAIN"' I I I I -C/ i�%n - }�„may
SERVICE I MOP SINK •
TOILETI
URINAL I I I I I I L
WASHING MACHINE CONNECTION I 1 I
WATER HEATER ALL TYPES / _ I I I
TER PIPING (IO/L4 a / I I
WA
• INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which,meets the requirements of MGL Ch.142. Y No❑
IF YOU CHECKED YES,PLEASE INDICATE TH E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Z OTHER TYPE OF INDEMNITY 0 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 Issued for this application will be in
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapternd 1General Laws.
PLUMBER NAME Mt e i'gt L ,6 cpiI 4 G L-( SIGNATURE���
UC# /7G 7 " MP JPJa�CORPORATION ❑# PARTNERSHIP ❑# LLC 0#
COMPANY NAME MIIC.44-c L Er s'®04-S1( ADDRESS: e20- lac flora` jQV C
crrY ly. /-74R. STATE-494. ZIP 0249 ?EMAIL'
TEL CELL crag- Pee 0I0 G FAX
ROUGH PLUMBING INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY
FINAL INSPECTION NOTES
s
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
REE: $ PERMIT it
PLAN REVIEW NOTES