HomeMy WebLinkAboutP-13-511 -.h
•
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
1-fip1
CIN �/tih (J N MA DATE �"7` PERMIT t# p/4`r7/
JOBSITE ADDRESS 2 S w I IU W f 7 OWNERS NAME O4V.e L 144464,9ti e(r
OWNER ADDRESS Z3 /1 I l v1.4-/ TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL p --
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES 0 NO 0
FIXTURES 1 FLOOR BSMT 1 2 3 4 5 6 7 6 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYS
DEDICATED GASIOIUSAND SYS
DEDICATED GREASE SYS
DEDICATD GRAY WATER SYS
DEDICATED WATER RECYCLE SYS
DRINKING FOUNTAIN
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
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substa al equivalent which,meets the requirements of MGL Ch.142. Yes No 0
IF YOU CHECKED YES, PLEASE INDICATE T 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 ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted(or entered) regardin• this application are true and accurate to the
best of my Knowledge and that all plumbing work and Installations performed uncle, t ' permit issued for • s appli .tl n will be In
compliance with
..all
lPertinent provision", lof the Massachusetts State Plumbing Code an. i`ter44 •f the Gena:al_J, -.
PLUMBER NAME Dl*/"1� i/ti]v4 11 SIGNATURE I '
LIC# 1 9Db! MP Jj❑ CORPORATION �# PAR /SHIP ❑# LLC 3 • 31)3
GI
COMPANY NAME CIV P.< 5V( Lt ( /' '�'b keI t ADDREESS: d VI Vt"be C4 ( J7
CITY frig-al t'-' STATEkk ZIP O9tt Q EMAIL
TEL -Thi-417) --rd? ) CELL F. 2 LS 0 7 l5
FE 07 2013 J
01.5f3 ilea- fi`
BUILDING DEPT
By (/�
1.1 w
l ROUGH PLUMBING INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY - FINAL INSPECTION NOTES
. • Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
• - PLAN REVIEW NOTES