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HomeMy WebLinkAboutP-15-1369 rfP /1 /2- • g, - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _uu1= t: CITY � I MA DATE lit1/6/IL'a! PERMIT# EtPPi6'-w/' v7 JOBSITE ADDRESS 12 3 fVerr , OWNER'S NAME r r c,YYCT' 1 P OWNER ADDRESS �3Ef � -FAX TYPE OR OCCUPANCY TYPE COMMERCIAL D EDU TI NAL © ' -'REFI E L PRINT SEPI B 20. ,PLN' SUBMITTED: YES❑ NO0 CLEARLY NEW Q , RENOVATION:❑ REPLACEMENT:0 FIXTURES-1 FLOOR BSM 1 2 3 4 6;, 11--- l 'SF•S 'l,,q- , 10 11 12 13 14 — BATHTUBi CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM 1- h i DEDICATED GAS/OILISAND SYSTEM i 1 % DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM — _ DEDICATED WATER RECYCLE SYSTEM { A DISHWASHER DRINKING FOUNTAIN , 1 FOOD DISPOSER .. . - -_ _ FLOOR/AREA DRAIN ; INTERCEPTOR(INTERIOR) ! • KITCHEN SINK LAVATORY . f I ' ROOF DRAIN _ SHOWER STALL SERVICE/MOP SINK 1 TOILET • URINAL - WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING i— i OTHER d ` -.- __. - . ._.� .___-. --_g tt INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW - - IJABIUTY INSURANCE POUCY❑+ OTHER TYPE OF INDEMNITY 0 BOND Q 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 ❑ 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 igco pliance I ertinent provision of the Massachusetts Slate Plumbing Code and Chapter 142 of the General Laws. - /`/ PLUMBER'S NAME ken duarte UCENSE# 11012 SIGNATURE - MPD JP , • CORPORATIOND# 3541 !PARTNERSHIP El# LLCD# COMPANY NAME duarte plumbing inc ADDRESS 37 collins ave CITY centerville ' STATE ma ZIP 02632 TEL 508-250-2763 FAX 508-775-9135 CELL EMAIL kenduarte37@hotmail.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES /?(e (. O'Z L12 Ce 9/a g/�r Yes No THIS APPLICATION SERVES AS THE PERMIT 0 0 FEE: $ PERMIT# PLAN REVIEW NOTES