HomeMy WebLinkAboutP-14-697 �-TV7 n auIa. 1 '--11---- 1QL-} (DRn I
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MASSACHUSETTS UNIFORM APPLICATIOII FOR A PERMIT TO PERFORM PLUMBING WORK
1 CITY a t I -U 171/ 1
i MA DATE PERMIT 11 J1- 69-
JOOSITE ADDRESS l-7 i5Qhll an- Ate_-- 1 ONMERS NAAE • �I 'Q a Aft ----'
P OWNER ADDRESS I IiFL
TYPE OR OCCUPANCY TYPE CCMrERGAL❑ EDUCATIONAL ❑ RESIDENTIAL( '
PRINT
CLEARLY NEW:L] RENOVATION:❑ REPLACEMENT:' PLANS SUBMITTED: YES[_J NOL I
FIXTURES 8 1 - - FLOOR-' T BSM j 1 J 2 3 j 4 1 5 i 6 . 1 T 1 8 j 9 1 10 1 11 1 12 j 13 j 14 -
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEMtip- r
DEDICATED GASCIUSAND SYSTEM `
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATm WATER RECYCLE SYSTEM ' _ __ -_ . 1 I I
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN ••
` .11
HTERCEPTOR(INTERIOR)
KITCHEN SINK•..
LAVATORY -
ROOF DRAIN - +
SHOWER STALL ,
SERVICE I MOP SINK
TOILET ' r
URINAL _-
WASHING MACHINE CONNECTION a +
I V E D
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BUILDING. MLNI INSURANCE COVERAGE
Imo, .-.�:..,n LWaWIrr.- --
ala substantial quivY�k which masa the requirements of MGL Ch.142 YES xi No j J
F YOU aECI(®YES,PLEASE INDICATE TIE TYPE OF COVERAGE BY CIEQOI G THE APPROPRIATE BOX mow
.UABIIJTY mamma CE POLICY® OTHER TYPE CF ICEMNTY 0 Baa 0 .
OWNER'S INSURANCE WAIVER:I wit aware that the imam dos not haw the krrna coverage nrpdnd by Chapter 142 of the
Maaachuntts General taws,and that my sipnshn on this prldt application mhos fMs nquanynant.
SIGNATURE OF OWNER OR AGENT SCK ONE ONLY: OWNER ❑ AGENT J
I hereby certify that at of tie des.rd Utnmsm I haw flanged or awed regaitirq U.appacsdon are bus and anisate b the best d my inasladge
rd that a plump aura rd krtakikns perk/mad mist to permit Isaad kr this application Wt be In mnptarre as Pertinent
Wceadaets State Pkmbkp Code and CMpter 142 d the General Lass. Pai4m of the
PLUMBER•SNAA€( \'recL.Qrlt-F: '(l)ox\-Ic,Yr, 1LICENSE 0 qZ% (SIGNATURE
LP JP CORPORATION® 'Z%cC IPARTNERSHIP❑ ILLC0Ar
COMPANY NAME G -` — __ -" ---
1 . .M gIc.,vr0:2in5Str,,ct, 14.4ADDRESSr� W2Ak,nci-ra+1 �.& I
CITY L\r,Lo\n 1STATE I WI- I ZIP 0Z5S,6 S TEI-i tiol 63`1 1-1461LL 1 . 1
FAX CELL 14 0l 631'1k+{i EMAIL I ---
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ROUGH PLUMBING INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ 0
FEE: $ PERMIT
PLAN REVIEW NOTES
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