HomeMy WebLinkAboutBLDP-15-004755 �r ✓ C M1/7finCr n S7-/5".%). /
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY WeAt Yet(rnOUth MA DATE 03/30/2015 PERMIT# //440,16'-taV
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JOBSITE ADDRESS 3 (nits lance Au // OWNER'S NAME Hubert HQrin%(Otc
OWNER ADDRESS g 3 iv/niiarrr, (� Y4rm,ocCh TEL 506-221.1680 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL ,
PRINT �/
CLEARLY NEW:❑ RENOVATION:IDREPLACEMENT:p9 PLANS SUBMITTED: YES❑ N01"
FIXTURES 7 FLOOR-' BSM 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 K n
DRINKING FOUNTAIN � JS 65.
FOOD DISPOSER
FLOOR/AREA DRAIN 7
INTERCEPTOR(INTERIOR)
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KITCHEN SINK yC
LAVATORY �f
ROOF DRAIN _ J _
SHOWER STALL
SERVICE I MOP SINK
TOILET
URINAL 111
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING -
OTHER
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL h.142. YES 0 NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BEL AN MAR 30115
UABILJ1Y INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY ❑ BOND ❑ BUIL U;NGC_P.,RTMENT
By: —
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laaww,,and-thatsn ignature on this permit application waives this requirement.
��2pF �/(�r'//0 f C{• CHECK ONE ONLY: OWNER AGENT ❑
SREOFOWNE' ORA NT
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 142 of the General Laws. _p _ v–
• PLUMBER'S NAME R c/< &vJTo1-4A7Xr LICENSE# 2$9 q, SIGNATURE
MP❑ JP E]' CORPORATION❑# PARTNERSHIP❑# LLC�#
COMPANY NAME R ; c/< & P/ven b.'c-&t 11"*.' ADDRESS 5-1 ABt/IS 40' a
CITY U-1 e5'T • >' i✓el.,od 71-7 STATE /Hit ZIP O2-A 73 TEL
FAX CELL/5'04 rat 0- 4'flr 3 EMAIL
ROUGII PLUMBING INSPECTION NOTES • BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT# -
PLAN REVIEW NOTES
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