HomeMy WebLinkAboutP-14-718 t
ICS:' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
N % CITY J • LittedtoM MA DATE ti'S U'i PERMIT# p/tI' 7
JOBSITE ADDRESS '7 (3Yrnt-tLh(i d �t OWNER'S NAME LCYiV .hFl! "-yP�
P OWNER ADDRESS TE600193.4aL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL p—
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
FIXTURES T FLOOR—, BSM 1 2 1 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR) _
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK
TOILET _
URINAL
WASHING MACHINE CONNECTION _ •
WATER HEATER ALL TYPES- n
WATER PIPING
''c
OTHER 0/ ltq/ro
APP, 3 0 2011. gr
C T r„l l=F.Ti
INSURANCE COVERAGE:
I have a 6uOeiit lia-biliitvinsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YE NO 0
IF YOU CHECKED YES,PLEASE INDICATE
THE HYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND 0
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: OWNER 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME JLICENSE#152P/ ;
MP E P CORPORATIONI:1#
— S
❑# PARTNERSHIP 0# LLC 0#
COMPANY NAMEfliP
_ ML4117r. ' • 'DRESS P b. Bqr 6 S6
CITY r`N r L S ATE t{`A-. ZIP CPSC 1 TEL JUf"317-9 9Q
FAX CELL$EBr 37-(177) EMAIL
_!Z'/ •
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: S PERMIT#
PLAN REVIEW NOTES