HomeMy WebLinkAboutP-12-026 4.
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO DO PLUMBING
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y � CITYITOWN:I V4ntut., , I APPLICATION DATE: 1I'AIL I
JOBADDRESS:I 3e St, ko IL si-44 ........D PLANS SUBMITTED: YESD NOD
POCCUPANCY TYPE: COMMERCIALE] RESIDENTIAL®
NEW 0 ALTERATION 0 REPLACEMENT(C REMOVAL/DEMOLTTIOND
r PLUMBING: PIPING-FIXTURES-FIXED APPLIANCES-APPURTENANCES 1
ENTER TOTAL AMOUNT FOR EACH SELECTION(LIMITED TO FIVE(5)NUMERALS
ALTERNATIVE TECHNOLOGY I- DISPOSER LJ SINK: MOPSERVICE U I
ASPIRATOR DRINKING FOUNTAIN f----1 STERILIZER
DRAIN: AREAE FLOORf 1 EJECTOR ❑ STORAGE TANK
BACKWATER VALVE �1 EMBALMING I I AUTOPSY I I URINAL
BAPTISM:FONT) I SACRARIUM n ',�I FOOD CHEST MISTING SYSTEM VACUUM DRAINAGE SYSTEM
BAR SINK I GLASS WASHER WATER CLOSET
BATHTUBL I WHIRLPOOL! I ,al ICE MAKER WATER HEATER:ALL TYPES
BIDET INTERCEPTOR:ALL INTERIOR WATER PIPING:
CROSS CONNECTION DEVICE KITCHEN SINK t OTHER NOT LISTED 1
DEDICATED: ACID WASTE SYSTEM - LAUNDRY CONNECTION
DEDICATED: GAS/OIL/SAND SYSTEM LAVATORY _tee
DEDICATED: GREASE SYSTEM S PIPE RELINING WORK ONLY
DEDICATED:RECLAIMED WATER ROOF DRAIN ,......'
DENTAL FIXTURE/EQUIPMENT MIN SINK: 1-2-3 BAY) PREP.0
DISHWASHER SINK:CLINIC C .FLUSH RIMn I
PLUMBING INSTALLER-FIRM-COMPANY INFORMATION CHECK ONE ONLY
NAME: ‘4."`-° k'A^ i ADDRESS:1 le etc, 1 -c
1/40‘il i i- VZ I 0CorporatIon Business I
CITY:
t _D.01nZnur{� ISTATE: ZIP: 2k `J --T� 3Partnership Business
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TEL: Irk-2 7.22P'le I FAX: I EMAIL:[ I OLLC Business 41 I
ElDBA/Unincorporated
NAME OF LICENSED PLUMBER: `C-4-1-1 col-e-W1/4
INSURANCE COVERAGE
I have a current liability Insurance policy or,its substantial equivalent,which meets the requirements of MGL.Ch.142 YESRI NO 0
If you have checked ygg please Indicate the type of coverage by checking the appropriate box below.
A liability Insurance policy Other type of Indemnity 0 Bond 0
OWNER'S INSURANCE WANERt II'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 wa(yq;this requirement.
CHECK ONE ONLY
Signature of(honeror Owner's Agern OWNER AGENT 0
OWNER'S NAME:! 9-'k Y_—CPt'P14Trp'i# 1 TEL:I t FAX:1— 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 Numbing Code,and Chapter 142 of the General Laws.
�(-O7FFICE USE ONLY) TYPE OF LICENSE:
Pent it T I -- 0 I ®Plumber
Inspector Master Signature of Licensed Plumber
Fee: 10 --Z.- ` ! [}]Journeyman R E C ELlc�da��Jatler. 300°`-/ I
II II 1 3 2011
ODING DEPT. -
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICADON SERVES AS THE PERMIT 0 0 ' •
FEES PERMIT
PLAN REVIEW (UM _
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