HomeMy WebLinkAboutP-12-015 !_ ....,
_SS. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO DO PLUMBING t
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CITY/TOWN:I Xiani101J �'� APPLICATION DATE D®-10,/ r
JOB ADDRESS: /GS 1/y ate ' A PUNS SUBMITTED: YES0 NOd"
pOCCUPANCY TYPE: COMMERCIAL RESIDENTIALD
NEIN❑ ALTERATION REPLACEMENT 0 REMOVAL/DEMOLRIOND
r PLUMBING: PIPING-FIXTURES-FIXED APPLIANCES-APPURTENANCES 1
ENTER TOTAL AMOUNT FOR EACH SELECTION(LIPeTED TO ENE(S)NUMERALS
ALTERNATIVE TECHNOLOGY DISPOSER I—, SINK: MOPLJ SERVICE LJ
ASPIRATOR DRINKING FOUNTAIN STERILIZER
DRAIN: AREA( I FLOOR I- ' EJECTORB STORAGE TANK
BACKWATER VALVE EMBALMING I I AUTOPSY I I URINAL
BAPTISM:FONTU SACRARIUM FOOD CHEST MISTING SYSTEM VACUUM DRAINAGE SYSTEM
BAR SINK GLASS WASHER WATER CLOSET / 1
BATHTUBI 1 WHIRLPOOLI I ,- ICE MAKER WATER HEATER:ALL TYPES
BIDET INTERCEPTOR:ALL INTERIOR WATER PIPING: /
CROSS CONNECTION DEVICE KITCHEN SINK '127 C OTHER NOT LISTED 1
DEDICATED: ACID WASTE SYSTEM LAUNDRY CONNECTION Imr.5%o&&.r • /
DEDICATED: GAS/OIL/SAND SYSTEM LAVATORY
DEDICATED: GREASE SYSTEM �I PIPE RELINING WORK ONLY
DEDICATED:RECLAIMED WATER ROOF DRAIN ....... "
DENTAL FIXTURE I EQUIPMENT ' I SINK: 1-2-3 BAYI ' PREP.0 (—
DISHWASHER / SINK:CLINIC n FLUSH RIM n I
PLUMBING INSTALLER-FIRM-COMPANY INFORMATION�-_ CHECK ONE ONLY
�E: s w /?/Mf �M3 I ADDRESS: 4 ird c7/•—^ 1 ['Corporation Business el
CITY: )4 '/nnee /re ISTATE: -_4' ZIP: -..$--- -J ['Partnership Business 11 I
TEL 91J87.2/71 pgf: IS11EMAIL:aafl Ws(7/'1 "7-54ant I ❑LLC Business ti
Li BA/Unincorporated
NAME OF LICENSED PLUMBER:
INSURANCE COVERAGE
I have a current liability insurance policy or,its substantial equivalent which meets the requirements of MGL Ch.142 YES ✓'NO 0
If you have checked yes please indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy la Other type of indemnity 0 Bond 0
OWNER'S INSURANCE WAVER 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
Signature of Owner or Owner's Agent OWNER,: AGENTEl
OWNER'S NAME:p/ /✓/C/I Lien-ri---—~- I TEL:I FAX: I
I hereby certify that all of the details and information 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,:
Peg t#*_ . ❑Pitanber
Signature of Licensed Plumber
Inspectorg---"VIIIIM%-is.J. IDMaster R E C E 1 ` C�NQn
Fee:
1 DJOurneyman �lf�nieNiinber.
JUL 1 2 2011070'616
BUILD NG DEPT.
By:
ROUGH PLUMBING INSPECTION NOTES
BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
r THIS APPLICATION SERVES AS THE PERMIT 0 0 •
FEE: $ PERMIT
PLAN REVIEW NOTES