HomeMy WebLinkAboutP-13-337 01'r'= Ace' S.y,
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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i=!!'41�ye CITY 5 . yARmocml _ MA DATE II a3 ( I� PERMIT#
JOBSITEADDRESS Iq busco--r- AVE OWNER'S NAME PJpRt3pCI I uL..e_../
P OWNER ADDRESS as rnecROSe 57- U2bwc.rcil TELL$-853-1931_FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL®
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:® PLANS SUBMITTED: YES 0 NO®
FIXTURES 7 FLOOR-. BSM 1 1 2 3 4 1 5 1 6 1 7 8 9 1_ 10 11 J 12 I 13 14
BATHTUB I t1_
CROSS CONNECTION DEVICE
T
DEDICATED SPECIAL WASTE SYSTEM 4 A L [ '
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM -4 ' 4
DEDICATED GRAY WATER SYSTEM ` t
DEDICATED WATER RECYCLE SYSTEM //
DISHWASHER s J
DRINKING FOUNTAIN
i.
FOOD DISPOSER
FLOOR IAREA DRAIN r y I
INTERCEPTOR(INTERIOR) 1, i , . I
KITCHEN SINK , p 1
LAVATORY r
ROOF DRAIN
SERSHOVE E� 1 1 E I MOP SIN r - r •iL� 7
/ 7-- ,
TOILET
Li;
URINAL .rjr=r___,
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES I 1
WATER PIPING 1
OTHER ,
m i i I lb„ ,
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESEI NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POLICY® OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:lam 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 ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application we 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 lance with al nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME CI-IR15 13Ria5 LICENSE#I/a901 I SIGNATURE
MP® JP 0 CORPORATION®#3a38 PARTNERSHIP 0# LLC 0#I
COMPANY NAME bill G5 t ne no RC 4( - ADDRESS P.O. 6c x 538
CITY ranrERUfu E STATE WA ZIP Cia43a bS ' 388/4
FAX 775-0 qty./ CELL EMAIL I ebr h S C GO I.COrn
07 J
X662 .iso,
BUILDING DEPT
ROUGH PLUMBING INSPECTION0VOTES a
ELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $
: PERMIT#
PLAN REVIEW NOTES
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