HomeMy WebLinkAboutP-14-457 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
to CITY rotr-�!!vrtt MA. DATE //4,�Y �-PPERMIT# Pig—
JOBsr EADDRESS 96 gI597-a)444-STe 12DW OWNER'S NAME bo4FLLSu)t 2-DZY
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OYYNERADDP,'eSS 69/J.oL<IP-�L -r'in flrFS//fiI�trjgELEL FAX
TYPE OR OCCUPANCYTYPE COM6dERCIAL❑ EDUCATIONAL 0 RESIDENTIAL*,
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
IX1U 1 FLOOR-. BSMTI 12 13 i 4 l 5 6 7 1 8 1 9 10 I 11 i 12 I 13 I 14
BATHTUB
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CROSS CONNECTION DEVICE I I
DEDICATED SPECIAL WASTE SYS I I I I
DEDICATED GAS/OIL/SAND SYS I I I I
DEDICATED GREASE SYS I I I J
DEDICATD GRAY WATER SYS I I I •
DEDICATED WATER RECYCLE SYS I
DRINKING FOUNTAIN I I
DISHWASHER I I
FOOD DISPOSER I I
FLOOR I AREA DRAIN I I
INTERCEPTOR(INTERIOR)
KITCHEN SINK I I I
-
LAVATORY 02. I • I .
ROOF DRAIN" I I ••
SHOWER STALL
SERVICE I MOP SINK • I I I I _
TOILET a- I I I I • I I
URINAL I I r I I I I
,WASNWGMACHINE CONNErt[N / l I I I I
. HPTtB4L4YIEESUJ / I I
OI ER -ICD I, 1 .
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BUILDINrr4RTMENT INSURANCE COVERAGE:
I I�ve a cu___lli nsurapce policy or its substantial equivalent which,meets the requirements of MGL Ch.142 . Yes16.No 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 4 OTHER TYPE OF INDEMNITY 0 BOND 0
OWNERS 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 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 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 NAME /OA rrr,� 1. t c,h afro SIGNATURE G
UC# y« k MP El JP❑ CORPORATION 0# PARTNERSHIP 0# LLC ❑#
COMPANY NAME (o A CTE 2 L O./t C 0 ADDRESS: In O`! cOL-o,IM AT
CITY /-I rrh d/4././S STATE MA LP 0e26o/ EMAIL
TEL So$ 7 7 a 5o3 9? CELL coF 726 5`?99 FAX
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LIQ ii-
ROUGH PLUMBING INSPECTION NOTES THIS PAGE FOR INSPECTOR UST ONLY
T+INAL UVSPUCTION NOTES
got- pLeo on 4.2fr it/tky Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 ❑
FEE: $ PERMIT It
Pi AN RLrVICW NOTES
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