HomeMy WebLinkAboutP-14-749 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING
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„ . . CI'iY N/f A-/� MA . DATE J
JOESITE ADDRESS /h /j II,- t. , �7_ 0 JNI3YS N.AME/. C(.'. 't/Y e
POWNER ADDRESS rSG ld7 P TEL FAX
61 TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDEht-Ii AL
5 �J{60
CLEARLY NEW:0 RENOVATION:0 REPLACEMEN TT PLANS SUBM 11 i ED: YES 0 NO 0
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D ICeFIXTURES: FLOOR-' I BSI 11 12 13 14 15 B 17 B I 9 I 10 I 11 I 12 I 13 14
fir° BATHTUB I I I I I I I I I
ICE I I I
C�a�lC CROSSDEDICATCED SPECIAL WNNECTION AS1 TE SYS I I I I I I I I
DEDICATED GAS/OILISAND SYS I I I I I I I I
DEDICATED GREASE SYS I I I I I I I I I
DEDICATD GRAY WATER SYS I I I I I
DEDICATED WATER RECYCLE SYS I I I I I I
DRINKING FOUNTAIN I I I I •I I I I
DISHWASHER I I . I I I I I I
FOOD DISPOSER I I I I ' I I I I
FLOOR/AREA DRAIN I I I I I I
flTRCtk'1uR(INiERJDR) I I I I I I I I •
KITCHEN SINK I I I I I I I I
LAVATORY -. I 1 I I • I I I 1
I ROOF DRAIN- I 1 I I I I I I
SHOWER STALL I I I I I I I
SERVICE I MOP SINK • I I I I I I I
TOILE I I I I I • I I I
URINAL I I I I I I I
I WASHING MACHINE CONNECTION I I I I I I I I
WATERHEATERALL TYPES I I 1 I . I I L I
WATER PIPING IL
OTHER I I I I I I Kir L..• L1: 1 \ E
I I I I I I --J1----1�Iy-_._
INSURANCE COVERAGE: AlM1 b t&rt
I have a current liability Insurance policy or its substantial equtvalentwhich,meats the requirements of MGL Cit 142 . Yes N o❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE Fa' AL dt�i
LIABIUTt'INSURANCE POLICY OTHERTYPE OF INDEMNITY 0 BOND 0 a t
OWNER'S INSURANCE WAIVER I ai aware that the licensee does not have the insurance coverage required by Chapter 142 of th
Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE BOX ONLY: OWNER 0 AGENT 0
Si.nature of Owner or Owner's •sent
I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to t
best of my Knowledge and that all plumbing work and Installations performed under the permit issued for this application will be
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chap r of the General Laws.
PLUMBER NAVE%C. j/ CA'•? SIGNATURE
LIC t"kr)ist MP JP TO CORPORATION alagii. P ER 1P 0i LLC ❑#
COMPANY NAME ADDRESS
7
ciiY. ge.,9OI //I STATE, LP 4J7 EMAIL
0 772-•C i 4 CELL FAX_
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THIS PACE FOR INSPECTOR USE ONLY -
FINALTNSPI;CTTON
ROUGH PLUMBING INSPECTION NOTES -
Yea No
I Is i• _ Cs ON SERV-9.ST E -Cu. 0 0
PEE: PERMITiI_�
ns Arrnrv1E OT13S
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