HomeMy WebLinkAboutP-12-690 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY 7.4l21,10UrnhIA. DATE 4/61oVi2 PERMIT# p/2--GADk
JOBSITE ADDRESS 5. 406v157 suaser Yne,"0011 -OWNER'S NAME 796tw taw
OWNER ADDRESS j/ f� TEL 779-ao8"IsOSFAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL(S"
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CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:tit PLANS SUBMITTED: YES 0 NO [R
FIXTURES 1 FLOOR BSMT 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYS
DEDICATED GAS/OIUSAND SYS I R t C F 1 V___�_E_y__
DEDICATED GREASE SYS
DEDICATD GRAY WATER SYS JUN WATER RECYCLE SYS JUN 2 rl 20121
DRINKING FOUNTAIN
DISHWASHER' BU LOIN ,riErART. NT
FOOD DISPOSER By'
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY •
ROOF DRAIN
SHOWER STALL
SERVICE!MOP SINK
TOILET
URINAL I 1
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
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 THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
• LIABILITY INSURANCE POLICY Pa' 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 0
Signature of Owner or Owner's 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 oft eeGGeenera)Laws.
PLUMBER NAME 2-"L'CAr7 u l'� 2 1/ 64 SIGNATURE •
LIC# 171 // MMP�//'��PH) -Tilt
CORPORATION a# Aga�J PARTNERSHIP ❑# LLC ❑##
COMPANY NAME
�/741/I ,A'W .T'tC ADDRESS: VVY OAO c i�9 eOAiO
CITY 5O''/// /2&#I»IYj STATE409 LP Og 64a EMAIL �-16.04o,-n,&P66U ,t red•-ver
TEL sor gr "c/%n CELL FAX 3S'66.
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ROUGH PLUMBING INSPECTION NOTES Tills PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT it
PLAN REVIEW NOTES