HomeMy WebLinkAboutP-19-3793 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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maww;c CITY/TOWN nt d'MQ DU MA DATE /d46!1 B PERMIT Avion-o .�77?
JOBSITEADDREESS 'aIcS(L°R LLC OWNER'S NAME (,/e , Maraget
P OWNER ADDRESS OA ct` ,tee., TEL (sb0 908 SB04AX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL Ere
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT: . PLANS SUBMITTED: YES 0 NO❑
FIXTURES 7 FLOOR esu 1 2 , 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM •
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK j `= t ; r
LAVATORY • C v i. S
ROOF DRAIN
SHOWER STALL DEC 2 6 201K,
SERVICE I MOP SINK f
TOILET
URINAL I' (Th
WASHING MACHINE CONNECTION
WATER HEATER All TYPES
WATER PIPING
OTHER
R A-acPlo✓
M/X/nIC //wide. /
INSURANCE COVERAGE: ' • ...
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL CR 142. YES( 'NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY LTJ 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 ONLY: OWNER 0 AGENT 0
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 arcuate 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 Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. , ,p rJ
PLUMBER'S NAME 3c,.4 Ca rc d I r - LICENSE# /69n d G SIGNATURE
MP Q JP❑ /CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME g44 Ce1A- •-) Pt'Ad ADDRESS F L/rotor 2)ti
CITY cri/t /Let/ A tt, STATEat ZIP QArr TEL t3 6 7JS= ✓ `c)
FAX CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ON! FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ 0 /J
FEES PERMIT# /'V; 1 G—t
PLAN REVIEW NOTES r)74f7,K14,4