HomeMy WebLinkAboutP-14-848 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
ter CRY Va, r�>rg MA DATE __ PERMIT# -84 8
cbil JOESITEADDRESS Y R2CP LN I OWNERS NAME C,r4+'D, A ///caV
P OINNEP DP EhC EIV F. 0 RESIDENTIAL
OS FAX
TYPE OR °COUP. Cv TYPE COIJId C I 0 EDUCATIONAL 0 RESIDIAL[[
PRINT JIJN 26 21114 /
CLEARLY NEW: PFJJOVATION:❑ PLACEMENT:Ly PLANS SUSMI I I tD. YES 0 NO 0
[km PITT hL PABTh1n:T
FIXNRESI DORS-- sstri ---1- -_ a 1 4 1 5 1 B 17 I B 9 10111112113 14
BATHTUB I I
CROSS CONNECTION DEVICE I I I
DEDICATED SPECIAL WASTE SYS I I
DEDICATED GAS/DILISAND SYS I I
DEDICATED GREASE SYS I I I
DEDICATD GRAY WATER SYS I I I
DEDICATED WATERRECYCLE SYS I I I
DRINKING FOUNTAIN I I
DISHWASHER 1
FOOD DISPOSER I
FLOOR/AREA DRAIN I I
B EERCEP l UR(INTERIOR) I _ I •
KITCHEN SINK - I I I
LAVATORY--. 2 I I
ROOF DRAIN-- I•
SHOWER STALL
SERVICE/MOP SINK - I I
TOILET 2 t I
URINAL I I I
WASHING MACHINE CONNECTION I I I I I
WATER HEAT ALL TYPES
WATER PIPNG I I I I
OTHER I i ) I
I
I I
• INSURANCE COVERAGE:
I have a currant liability Insurance policy or its substantial equivalent which,meats the requirements of MGL Ch.142. Yes 21.:1 e❑
IF YOU CHECKED YES, PLEASE INDICATE E TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHERT(2E OF INDEMNITY 0 BOND b
OWNERS INSURANCE WAIVER:I am 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 •
Signature of Owner or Owner's Agent
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 Chapter 142 of the General Laws.
PLUMBER NNE SrE PI+LM b. &w I N 6 SIGNATURE -1
LIC# /5-21/ MpLY JP❑ CORPORATON ❑d PARTNa- 'is 0# LLC ❑#
COMPANY NAME an/area PwHBuv6« ,/66r/N6 ADDRE55: p D. /3ox 6.re
CITY c3964yotie STATE fIR zip 025.6/ E,riAli: STEvL(EDGCWATLeA.ufrINGINC, tort
1 Sob) 317 - ql to e'O 08j(Sop) 737.0077 FAX
TIUSPACEFORINSPECTOR UST ONLY
F1*�A r 1NSPLICTrON NOT"
ROUGH PLUMBING INSPECTION NOTES
Yes No
1. 5 :' C. SiSEIV-9 'S - :Iu 0 0
FEE: S_--- PERMIT P______----
PI AN_ RL�'1FW1`1�L5
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