HomeMy WebLinkAboutP-12-227 -. MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM PLUMBING WORK
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;11:1:7 CITY I Yamwuth 1, MA DATE I /Y- I` 6101/ Pawn-ii)2--227
JOBSITE ADDRESS I y,7 G is ru f o n/ D A I OWNER'S NAME I A• L yT L e
P OWNER ADDRESS N,1. C I I f-o N n
I D ITEL•I774 5149FaxI
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:rar RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO 0
FIXUTRES 1 FLOORS-6 Elsie 1 2 3 4 5 8 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONN DEVICE
^A r n P' A !
DEDICATED SPECIAL WASTE SYS
DEDICATED GAS/OIL/SAND SYS _ - - g�
DEDICATED GREASE SYSTEM NO 0 ✓L U S T
DEDICATED GRAY WATER SYS -tr.3 6\
DEDICATED WATER REUSE SYS ��
DISHWASHER
,-
DRINKING FOUNTAIN --
FOOD WASTE GRINDER UNIT
FLOOR/AREA DRAIN
INTERCEPTOR INTERIOR
KITCHEN SINK 840.-sr'✓tC I
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
INSURANCE COVERAGE
I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 2ra 0
if you have checked please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POUCY 12" OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAVER:I am aware that the licensee does not havq the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application nits this requirement
• CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the digit's and iafonnatlon I have submitted(or entered)regarding this application are true and accurate to the best of my
Knowledge and that at plumbing work and installations perfamed under the pemnt Issued fa Nb application wit be In co Welt
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _
•
PLUMBER NAMEIFgAU41_5 E Do//C ILICENSE# ; f0
SIGNATURE
COMPANY NAME: I FRnv 7 041e. PSK Znh - IADDRESS:I P.O 6ex Gro
CIIYAny pa t ISTATE: el'ra ZIP: I 026 7Z
I FAX: ( S0b'362-781 r
TEL: Ir05' 77c_ r91r (CELL•IsFr732-n9o2IEmAti
MASTER ECOURNEYMAN 0 CORPORATIONc 13?`1-1 PARTNERSHIP 0 III I LLC❑#
• 'PM-
JIELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
ROUGH i INSPECTION NOTES A
Yes No -DO-ll f`I f ( n /9 ' KL-
THIS APPLICATION SERVES AS THE PERMIT 0 0
• FEE: S PERMIT
PLAN REVIEW NOTES
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