HomeMy WebLinkAboutP-14-816 t . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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JOBSITE ADDRESS oiri , OWNER'S NAME �Oi.'_. K(r f�( ,S(1r l
P OWNER ADDRESS TEL)k7(o3jrr-yyaFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIALO
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 6 i 9 10 11 12 13 14
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BATHTUB - ' r ( .. - ;-_. _n i_. f - - -t-, -Ir. w I, . _ ; -
CROSS CONNECTION DEVICE j 1
DEDICATED SPECIAL WASTE SYSTEM I . 1 ,r 1 r r f 1 [ I i
DEDICATED GAS/OIUSAND SYSTEM „t s i
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
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FLOOR INTERCEPTOR
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INTERCEPTOR(INTERIOR) iIIIiiIIiII.Iijj
SHOWER STALL � f �MIMPS� �
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TOILET ,
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WASHING MACHINE CONNECTION I, I
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BYE_ —__ INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[. NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY(g] OTHER TYPE OF INDEMNITY ❑ BOND ❑
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 ar- f e 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 • plias a with a Perti provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `V�
PLUMBER'S NAME Lncpi j Cemyin iii LICENSE# /29-9', , SIGNATURE
MMM JP❑ CORPORATION0f 3E040 PARTNERSHIP 2# LLC❑#
COMPANY NAME eon Plum b)nc1 ADDRESS / CUP I I On CI -I-on k'Qra A_
CITY L ep J/4 STATE gl _ ZIP 0 Z Vag _ TEL Lk I— 4,39- 480
FAX CELL EMAIL hi—inn/W14Yn 0 ete1eY1Pk)1116W1ct r 0nw
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 it
PLAN REVIEW NOTES
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