HomeMy WebLinkAboutP-12-065 II
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO DO PLUMBING
E =`,-n'_ CITY/TOWN.i 71Q'' ,'-touts 1 APPLICATION DATE:! 3/2 hi 1
JOB ADDRESS:I-7y C1 ,&.-t t1 p/2/t'' 1 PLANS SUBMITTED: YES O N0o-
POCCUPANCY TYPE: COMMERCIALD RESIDENTIAL[i'
NEW0 ALTERATION REPLACEMENT0 REMOVALJDEMOLIIIOND
C PLUMBING: PIPING-FIXTURES-FIXED APPLIANCES-APPURTENANCES 1
ENTER TOTAL AMOUNT FOR EACH SELECTION NMTTED TO FIVE(5)NUMERALS
ALTERNATIVE TECHNOLOGY DISPOSER ( SINK MOP(J SERVICE[1 ,
ASPIRATOR — DRINKING FOUNTAIN STERILIZER
DRAIN: AREA FLOOR EJECTOR 0, STORAGE TANK
BACKWATER VALVE EMBALMING 1 I AUTOPSY I I URINAL
BAPTISM:FONTn SACRARIUM❑ — FOOD CHEST MISTING SYSTEM VACUUM DRAINAGE SYSTEM
BAR SINK GLASS WASHER WATER CLOSET
BATHTUB( I WHIRLPOOL) 1 ' ICE MAKER WATER HEATER:ALL TYPES ✓
BIDET �s INTERCEPTOR:ALL.INTERIOR WATER PIPING:
CROSS CONNECTION DEVICE — KITCHEN SINK t OTHER NOT LISTED 1
DEDICATED: ACID WASTE SYSTEM �_ LAUNDRY CONNECTION
DEDICATED: GASIOIUSAND SYSTEM LAVATORY 1% _
D se
DEDICATED: GREASE SYSTEM �! PIPE RELINING WORK ONLY ' L` i euT C
vl DEDICATED:RECLAIMED WATER m�� ROOF DRAIN r ,, ^r
fi DENTAL FIXTURE/EQUIPMENT SINK: 1.2-3 RAYL, PREP.�J [ f r' u
W DISHWASHER _ SINK:CLINK: ❑FLUSH RIM❑ L_� ____
ii‘j PLUMBING INSTALLER—FIRM-COMPANY INFORMATION rq .. "''CHECK ONE ONLY 1
`D NAME:r a;-- T: G ' ADDRE�SSS:: / Sti"?/H*� 5-7-1 L_JCiapoiavon Business 4,...,_____I
CITY: `1 u_ G STATE: , 1 ZIP: O/ OC J OPa1nership Business 111—._____ 1
TEL: - . 1- 103 FAX:F-7-1 EMAIL ----/ ❑LLC Business al
Btik Unincorporated
411/4 NAME OF LICENSED PLUMBER:
N
INSURANCE COVERAGE
u
I have a current liability Inst antepolicya,its substantial
equivalent,which meets the requirements of MGL CBL 142 YES[rNO u
If you have checked yes,please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy Er- Other type of indemnity 0 . Bond 0
OWNER'S INSURANCE WAIVER:1 am aware that the licensee sIttessa have the Insurance coverage required by Chapter 142 of the Massachusetts General Laws,
and that my signature on this permit application waiya this requirement.
CHECK ONE ONLY
Signature of Owner or Owner's Agent T OWNER❑ AGENT
OWNER'S NAME:I S a qts /C4 G+T 7 —�. }TEL:[ I FAX: I
I hereby certify that all of the details and informatics I have submitted(or entered)regarding this permit application is true and accurate to
the best of my knowledge.I certify that all plumbing work and Installations performed under the permit issued,will be in compliance with
all pertinent provisions of the Massachusetts Uniform State Plumbing Code,and Chapter 142 of the General Laws.
(OFFICE USE ONLY) TYPE OF LICENSE,:
pep( h v— 06,1c
I D Plumber
Inspector Master Signa of Licensed Plumber
!
fLicense Number. 3/ Thi�/ I
Fee:I Journeyman
BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
BOUGH PLUMBING INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: S PERMIT!<
PLAN REVIEW NOTES
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