HomeMy WebLinkAboutP-14-300 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK I
,, x•''`• Z—CV CITY 7//72+100771 - - WA DATE 1a-31' 2a3 P
PERMIT# /2/7.-300
JOBSITE ADDRESS/ /55 M/91N 5i a,4) OWNERS NAME �T4C±? fA11
P OWNER ADDRESS 15-9 19rtirl .S Mt) TES'th 4, -aiy 2 FAX
TYPE OR OCCUPANCY TYPE COMJdERCIAL' EDUCATIONAL 0 RESIDENTIAL •
PRINT
CLEARLY NEW:0 RENOVATION:0 RE LACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
FIXTURES Z FLOOR-I. BSMT 1 I 2 I 3 4 I 5 I 6 I 7 I 6 9 I 10 I 11 12 I 13 I 14
BATHTUB I I I I I
CROSS CONNECTION DEVICE I I I I I I
DEDICATED SPECIAL WASTE SYS I I I I I _
DEDICATED GAS/OIUSAND SYS I I I
DEDICATED GREASE SYS I I_ _
DEDICATD GRAY WATER SYS I I I I I
DEDICATED WATER RECYCLE SYS I I I
DRINKING FOUNTAIN I I
DISHWASHER I I I I
• FOOD DISPOSER I I _
FLOOR/AREA DRAIN I
INTERCEPTOR(INTERIOR) I I
KITCHEN SINKI I I
LAVATORY-•-. / I
ROOF DRAIN- I I I
SHOWER STALL _( I I I
SERVICE I MOP SINK • I I I I I I
TOILETI I I • I I I I
URINAL I I I I I I i
WASHING MACHINE CONNECTION I I I I
WATER HEATER ALL TYPES / I I I I
WATER PIPING I I I I I I I
OTHER 111 I I II I
• - INSURANCE COVERAGE:
\ I have a current Liability Insurance policy or its substantial equivalent which,meets the requirements of MGL Ch.142. Yes No 0
Cj 1 r OU CHECKED YES,PLEASE INDICATE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
W 4 LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND ❑
N �( ER'S INSURANCE WANER I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
sachusetts General Laws,and that my signature on this permit application waives this requirement
V 1 F— CHECK ONE BOX ONLY: OWNER 0 AGENT 0' V co �I
1:ture of Owner or Owner's Agent
W
c Eh---by certify that all of the details and information 1 have submitted (or entered) regarding this application are true and accurate to the
Bt of my Knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be In
ompliance with all Pertinent provision of the Massachusetts State Plumbing Code an hapten 142f the General Laws.
PLUMBER NAME 1 it'll-Pt SIGNATURE
uc#MIS/3l4?o MP JP❑ CORPORATION gifigrePt9 PARI HIP ❑4 ac ❑# •
COMPANY
NAME -J,31 072: ADDRESS: C %//?///7 Y-/hc A -Art 14
CITY '�2t v.57Y.2 STATE/I,7ZIP°�3� EMAIL 7XJU� -79711yinti)L 7>4
/�Ql2
TEL L qI/ '722-9J7c CELL 7Qq•722-917r FAX :SDPail.47/8
•
LPA
ROUGH PLUMBING INSPECTION NOTES TIRS PAGE POR INSPECTOR USE ONLY
PINA INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 ❑
FEE: $ PERMIT ft
PL Rsi . \O"ES
----------------------
i