HomeMy WebLinkAboutP-13-098 RS Ssa.`
t'a 7%0MASSACHUSETTS UNIFORMAPPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
ira CITY \ ANI`( 'h16UM 1 MA DATE t'Nra. PERMIT# 19,b- 098
'. JOBSITEADDRESS R Willy0C (ro, OWNERS NAME UthlLItt — I 1
P OWNER ADDRESS u VN.lI'M Ln I TEL 44154, S IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:El RENOVATION:❑ REPLACEMENT:EI2 PLANS SUBMITTED: YES❑ NOD
FIXTURES 2 FLOOR-+ BSM 1 2 3 4 5 8 7 8 9 10 11 12 13 14
BATHTUB I. i[ II [ i[
CROSS CONNECTION DEVICE . I I r [ 'I �[ �I X11 r I
DEDICATED SPECIAL WASTE SYSTEM ��-, I Ii i- I
DEDICATED GAS/OIL/SAND SYSTEM [ 'I— IF I ,
DEDICATED GREASE SYSTEM 'iIM-,� ;S;. :
DEDICATED WATER RECYCLE SYSTEM mus `� Iat 1I
DEDICATED GRAY WATER SYSTEM
DRINKING FOUNTAIN alai 'sinning I __I En a 'a
FOOD DISPOSER
Matill
FLOOR ..IN. �..INTERIOR �� r ���rtt��� � r
a sr
au k
KITCHENS K �111� __ is, __ ,
ROOF DRAIN
SHOWER STALL
�.. flr� � I_w w �w �fl
SERVICE I MOP SINK TOILET .111 rr MI
URINAL _ ;I
WASHING MACHINE CONNECTION I [
WATER HEATER ALL TYPES
WATER PIPING r--11ISI
OTHER F-1
En! TM
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Er O ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ - BOND Ei
OWNER'S INSURANCE WAIVER:l 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 ❑ 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 complia Et itttal .' ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,7e/
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PLUMBERS NAME �aST \ktile3ra ILICENSE# gnat/ ' ATtIR
MPaP❑ CORPORATION# 7c2S5 PARTNERSHIP❑# ac 0#
COMPANY NAME a A is ,,,,,... lei, ,` f „ ADDRESS idi'UK.r Pa,
CITY St yanywn lit 'STATE , I ZIP TEL
TEL SCe_ R-(C1,0/
FAX CELL .9.%,/,-.5:59 EMAIL • 0e@ VJC1 h,literv-Atgiri`arI/Jy e CS I
14u1US
is
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