HomeMy WebLinkAboutP-12-012 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO DO PLUMBING f
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[ ?m'_ CITYITOWN• Watm — 1 APPLICATION DATE: 701 y U Z a'I I
JOB ADDRESS] I5- Set aait bv'oak . —I PLANS SUBMITTED: YES El NO0
POCCUPANCY TYPE: COMMERCIALE] RESIDENTIAL®.
NEW 0 ALTERATIONS REPLACEMENT 0 REMOVALA)EMOUTIOND
C PLUMBING: PIPING-FIXTURES-FIXED APPLIANCES-APPURTENANCES 1
ENTER TOTAL AMOUNT FOR EACH SELECTION(LIMITED TO FIVE(S)NUMERALS
ALTERNATIVE TECHNOLOGY —, DISPOSER I SINK: MOPU SERVICE[L
ASPIRATOR DRINKING FOUNTAIN f STERIUZER
DRAIN: AREA[, FLOORf1 — EJECTOR ❑ STORAGE TANK
BACKWATER VALVE EMBALMING l I AUTOPSY I_ I URINAL Sif
BAPTISM:FONTI I SACRARIUM I I ' FOOD CHEST MISTING SYSTEM VACUUM DRAINAGE SYSTEM
BAR SINK GLASS WASHER �� WATER CLOSET
BATHTUBL I WHIRLPOOL' I _� ICE MAKER WATER HEATER:ALL TYPES
BIDET
mamma INTERCEPTOR:ALL INTERIOR WATER PIPING: •
CROSS CONNECTION DEVICE KITCHEN SINK 'T'
es. KITHERNOTLISTED Z
DEDICATED: ACID WASTE SYSTEM LAUNDRY CONNECTION
DEDICATED: GAS/OIL/SAND SYSTEM = LAVATORY /J`
DEDICATED: GREASE SYSTEM PIPE RELINING WORK ONLY IQ, 12011
Li„. DEDICATED:RECLAIMED WATER ROOF DRAIN
DENTAL FIXTURE(EQUIPMENT , � SINK: 1-2-3 BAY( PREP. j l 00
DISHWASHER I .0SINK:CLINIC fl FLUSH RIM [_ c�'u 7-7177—
BY
PLUMBING INSTALLER—FIRM-COMPANY INFORMATION HECK ONE ONLY
NAME: TQ ac Kq WC I ADDRESS: 31Faa- ';N;o yvtpy ,C ❑Corporation Business II J
•
CITY: S• 4Y`"� --V STATE: I ZIP:( O266Y .- j DPannership Business'I
TEL: 1 39 ` -arq 74FAX:( EMAIL:! 10LLC Business/I I
NAME OF LICENSED PLUMBER: •
0 DBA 1 Unincorporated
INSURANCE COVERAGE
I have a current liability insurance policy or,its substantial equivalent,which meets the requirements of MGL Ch.142 YES[3 NOD
If you have checked Az please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy® Other type of indemnity 0 Bond EI
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
Signature of Owner or Owner's —Agent 1 OWNERD AGENT 0
OWNER'S NAME: — � TEL:(_ ( FAX: I
I
that all of the details and
the best my knowledge.I certify that all pluming work and Instaltion I have ls ions performedrunder the this�K application is issued,will be in
and accuratentewith to
all pertinent provisions of the Massachusetts Uniform State Plumbing Code,and Chapter 142 ofpermthe dGeneral Laws. In compliance
(OFFICE USE ONLY) TYPE OF LICENSE:
Perm#r%y [� I .plumber
inspectors Alif, r �_` Master S nature of Licensed Plumber
' Lice a umber: a 7S5— I
Fee: / / `fs aioumeyman
BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
art ROUGAPLUMBIIeHCQ}INtSJPcEC�ION NOTES ,f�
13_I 1 ( GL
THIS APPLICATION SERVES AS TIE PERMIT y
Oat faA01,\y --
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FEE: $ PERMIT i p 12-di Z
PLAN REVIEW NOTES