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HomeMy WebLinkAboutP-12-677 if y MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK J_I= >! CITY • r $ 14 4 MA DATE I(,-/ _/ PERMIT C/ JOBSITE ADDRESS )n7 5Ar 1 '^ cakpifilOWNER'S NAME Civ C�yTW-. t POWNER ADDRESS U. S r• W r r , ri_ rt TEL 6t j -941 -Thu IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL© EDUCATI NAL © RESIDENTIAL 1,2-•"---- PRINT ,2-"PRINT CLEARLY NEW:® RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES Q NOD FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I i 1[ l 1[ [ ! [ [_ _ 1[ Q [ CROSS CONNECTION DEVICE I DEDICATED E DEDICATED GAS/COIU ANDTSYS EM SYSTEM W [ ,m =] DEDICATED GREASE SYSTEM f-_ _. _-i [�� �u'% j DEDICATED GRAY WATER SYSTEMIS ininallatoestfrou DEDICATED WATER RECYCLE SYSTEM esollS5; , 51 .111j1_ !�A,11P 't%'n 'L DISHWASHER Sra siaas !SsnSSI : DRINKING FOUNTAIN 55 Imo' [5Ia;a'I,s',A la _ r_*I_ FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR KITCHEN SINK � LAVATORY [M ROOF DRAIN SHOWER STALL O5I SERVICE I MOP SINK 11 'ar ! [ r MUM URINAL :shaSl�l�!l ��I [_r as— WASHINGnrimilla SIMS WATER HEATERINE ALL TYPESCTIffiON� lW21 lallan.111110111111USIMI Ma WATER PIPING OTHER iSl[—[S [SSSSSSSM[sa1— r .W .5 ! i INSURANCE COVERAGE: / I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES j NO Lei IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY Q 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 D AGENT 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 compliand- 'th-al P_eg'. ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,5 ', '�oSeeft /Sinn NAME i . ` '�Pryff!P3�n (LICENSE# I�0 � MPPIQ CORPORATION[r#af►�sPARTNERSHIP D#111.1.111LLCD# COMPANY NAME _South Sivort }4a, 64. 1 ADDRESS r.” ' CITY 3,, Yattplikl. .1 STATE AM. ZIP 02.66,1-1 1 TEL _5V-89g,OW FAX CELL ) ,12-17 EMAIL J. _O) Ti . o_. 2n , ,CQr/1 1 * 11322 j 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 •