HomeMy WebLinkAboutP-15-1738 , � MjASSACHUStt is UNIFORM APPLICATION FORA PERMI I I U rttcruecM ruuinainta VVOKK
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� or JOESffE ADDRESS
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POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCYTYPE COMMERCIAL EDUCATIONAL 0 P,ESIDB4TtkL❑
PRINT
CLEARLY c NEW:0 RENOVA lON:❑ REPLACEMENT:❑r PLANS SUBMITTED: YES❑ NO 0
FI TURES2 FLOOR-4. ssM1 11 12 1 3 1 4 5 1 n 1 7 I e 1 9 10 11 I 12 13 1 14
BATHTUB
CROSS CONNECrON DEVICE I I I I I I I I I I
DEDICA i rD SPECIAL WASTE SYS I I I I I I I I I
DEDICATED GAS/OILISAND SYS I I I I I I I I I
DEDICATED GREASE SYS I I I I I I I I
DEDICATD GRAY WATER SYS I I I I I I ) I
DEDICATED WATER RECYCLE SYS I I I I I I
DRINKING FOUNTAIN I I I I I I I I I
DISHWASHER I I I I I I I I
FOOD DISPOSER I I I I
FLOOR/AREA DRAIN I I I I I I
II TEERCFPTOR(INTERIOR) I I I I I I
KITCHEN SINK I I I I I I I I
LAVATORY-.•. I I I I .1 I
ROOF DRAIN— I I I I' I I I I
SHOWER STALL
SERVICE J MOP SINK - I I I I I I I I
TOILET I I I I I I I .
URINAL
URINAL I I I I I I I I J
WASHING.MACHINacONN I I I I I I I I I
vvATERHaAtraapEs c U I I I I I I I—
WATER.PrIPiNeoL'lj j y - I I I
OTHER I L N �7 I I I I I I I I
I SEP 2yNth I I I I I I I
I I I I I I I I I
RUILDING Trr1ENT INSURANCE COVERAGE:
I hat a,currant_ msurenca got oy or its substantial equivalent which,meats the requirements of MGL Ch.142. Yes 9 No 0
IF YOU CHECKED YES,PLEASE INDICATE t E TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHEERTYPE 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 ti
Massachuset s 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 Owners Agent
I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to
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 he Massachusetts State Plumbing Code an• • apter 142• the General Laws.
PLUMBER NAME J 1 10 'c -cA t noKJYL1roe SIGMA it!ll1 I ASA
UC# -/(V 11 WP�r JP❑ CORPORATIION ❑4 c ,/PARTNERSHIP ❑# LLLC ❑#
COMPANY NAME it i x(21 TI r6 4e y3tiv AD' °
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crrrMA(wui M(�-lS STATE Meq zp61,0YBAAL
TEL 03 737 O // CELL FAX_
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EINAr TNSPLrCTTON °TES
ROUGH PLUMBING INSPECTION NOTES
TTTTS PAGE POR TNM+CTOR USE ONLY
Yes No
I S ;• C OSE vEs f T ° - • 0 0
FEE: S_-- PERMIT 1/
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