HomeMy WebLinkAboutP-18-6554 •
t - _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING*02/9-00
WORK
4 CITY SUtrtFA 4A1LMWtU MA DATE Sintt� PERMIT# #*D/9/f QO66
JOBSITEADDRESS '12.. L&T&OS STA4LPY Lts. OWNER'S NAME AO(s
OWNER ADDRESS TEL CoA-ckFt-gee.\ FAX_
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL /FA
PRINT
CLEARLY NEW:0 RENOVATION:ID/ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NOe
FIXTURES 7 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB I •
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM _ •
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER t •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN _
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY 2 •
SHOFERST ' —• .
I SHOWER STALL . r ti •
SERVICE/MOP SINK
I TOILET •
URINAL r H�i I / /011 t
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES I• 114 6 do f e 6i I as, (
WATER PIPING (LAW
OTHER
Lio1LPl
•INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 'NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIU•fY INSURANCE POUCY V 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 ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
LU 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.
PLUMBERS NAME Make_k AL 'aa►toviseJ LICENSE# l't(4 S. SIGNATU tU
MP V JP❑ CORPORATION❑# PARTNERSHIP Q# LLC❑#
COMPANY NAME CA#EWtcf Pwwxtyl.s&c HVaiLlfr ADDRESS ns- eA v\tU SMkU_ 11.Q.
CITY C. coniMLtfriA STATE AA- ZIP 07.064 TEL '1'1K-114 ^169'4
FAX CELL EMAIL (Mn ttfa'rPLLIhthud&(3YMNU0 1ahr•
ROUGH PLUMBING INSPECTION NOTES )3ELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
/,gf �� / THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ qf�/ ' /� /�J�/�
/4 ' FEE: $ PERMIT# //� v !/f Gr/ GAO
/All I PLAN REVIEW NOTES (/ [[l