HomeMy WebLinkAboutP-13-674 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
is CITY S. yarmol1lii MA DATE �3 PERMIT# /
JOBSITE ADDRESS 1R 7 eR1vEQ S-fr OWNER'S NAME ott-o 'nvnnrr
OWNER ADDRESS 187 'IvEv 3+ TEL 5o8 - 391- `/7/ZFAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0,
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:L. PLANS SUBMITTED: YES❑ NO El
•
FIXTURES 1 FLOOR-. BSMT 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB •
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYS
DEDICATED GAS/OIUSAND SYS
DEDICATED GREASE SYS
DEDICATD GRAY WATER SYS
Q/90 DEDICATED WATER RECYCLE SYS
V DRINKING FOUNTAIN
DISHWASHER
FOOD DISPOSER -
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY _
ROOF DRAIN
-`
SHOWER STALL
SERVICE/MOP SINK •
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
`tar SinK >c
• INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which,meets the requirements of MGL Ch.142. YesA No❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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 Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 the General Laws.
J
PLUMBER NAME JCL ---050-3l1E2, SIGNATURE
LIC# 12470 NIP❑ JP CORPORATION 0# ARTNERSHIP ❑# f�?L LLC ❑#
COMPANY NAME J,/ Downey 1/ornimn ADDRESS: 76 �
y} cooIC+ Break' rd
CITY `l, yarmo✓ 4ti STATE 're ZIP +61 EMAIL. �/r ps'Wn2y6o/e G I1 ,Cour
' 2z/-S-Zr
TEL r s CELL e- J
•
AFR 0 8 2011
t,,t, �a. d
J�.niG'DEPT
ROUGH PLUMBING INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
n/p f THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
y/Co//3 FEE: $ PERMIT It
PLAN REVIEW NOTES