HomeMy WebLinkAboutP-19-3726 •
MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
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- CITY StsuTl& YA/ukatt4 MA DATE f 2 119 I 1 S PERMIT# ttp-CV37 Q
JOBSITE ADDRESS 2l CAITA-U.j Swi LEY At OWNER'S NAME CtLEG- NUmISO.J
POWNER ADDRESS TEL 4c0$-3yS-r(QG( FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL e
PRINT �/
CLEARLY NEW:0 RENOVATION:L� REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7 FLOOR-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OILISAND SYSTEM
DEDICATED GREASE SYSTEM -
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM .
DISHWASHER • '
DRINKING FOUNTAIN _
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) _
KITCHEN SINK
LAVATORY
ROOF DRAIN r..7 - (• __ t t r l' , 1
SHOWER STALL
•
SERVICE I MOP SINK i
TOILET I JtL 19 I Ed
URINAL i I ;
. WASHING MACHINE CONNECTION - I ""
WATER HEATER ALL TYPES 1 {Y,i,. „ r
WATER PIPING
OTHER
4Y11UT`4 \ 4.114.11C—I
St4r- MSF rFeat)? GMP t
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES izi,NO 0
IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY {!f 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
i Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE ONLY: OWNER 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT
L1 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 peri 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.
PLUMBER'S NAME MICMJrCL 4— "bo kluJA#-S LICENSE# 61-0.1 3 , SIGN1/1
ATURE
MPr( JP❑ CORPORATION❑# PARTNERSHIP 0.# LLC❑#
COMPANY NAME Osietvlkit. druMM4,IG '` Walk?'& ADDRESS t'35- CAPLkt4 SW&L CO.
CITY S VAI. M.•trtK STATE MA ZIP a1GraN TEL-1')N-lliy - (8t
FAX CELL EMAIL 40 EA)\UFQ11f'M C 'MJOd. (OMS
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT# ,/�"Q� ,C`� /�/Z�"j�P�p- Ce---
PLAN REVIEW NOTES v e t5 (oz// O/,'