HomeMy WebLinkAboutP-13-430 SO 00
I.C. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
7.lir �C CITY -S ornic H- i ( MA DATE / �2 ? I PERMIT# Pi✓— c'30
JOBSITE ADDRESS lop.. (t'(fdedd Rd I OWNER'S NAMES a-61/4y Ice- AClie- I
P OWNER ADDRESS LSAMe ! TEL fi J?-/,?B71FAX "--
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL[11--
PRINT
WPRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:[EV PLANS SUBMITTED: YES❑ NOQ—
FIXTURES 7 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB pli
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM - '
DEDICATED GAS/OILISAND SYSTEM ,
DEDICATED GREASE SYSTEM I ,
DEDICATED GRAY WATER SYSTEM i-
DEDICATED WATER RECYCLE SYSTEM is. - r T ,
DISHWASHER
DRINKING FOUNTAIN [�
FOOD DISPOSER _ n _ , , i i LSA
FLOOR/AREA DRAIN 1
INTERCEPTOR(INTERIOR) t— 11 ,i
KITCHEN SINK
LAVATORY Ls NIII
. . _
ROOF DRAIN � "'
SHOWER STALL
SERVICE/MOP SINKI/. . ,, , _
r
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPINGv
OTHER r
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES a-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 ❑
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 ONLY: OWNER ❑ AGENT 0
SIGNATURE OF OWNER OR 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 of the General Laws. f • Z
PLUMBER'S NAMED 6,41Szre, th L -ILICENSE# 93,77 re i SIGN U
MP' JP❑ CORPORATION[j# PARTNERSHIP❑# JLLC❑#
COMPANY NAME rf 4 'l ,,f; ADDRESS / pr Alec /v ior w
CITY / y P,,,ry-- STATE rig ZIP 0o24-cy7 TEL ,Sze J?8•-3 r c
FAX ( CELL EMAIL / / r 7 . :t. i
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— Erls7 LC-WC-3;4y
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES