HomeMy WebLinkAboutP-15-052 - - --,--s, mass c�HusETTTS UNIFORM APPUCA HUN rLKA rnru,1 I I U r urun r 4_L+w,o,1rvL, vvura\
r� = um' , (�� MA. DATE ri ``� CPEPJ�NT? 0--s2.
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JOESITE ADDRESS a _ L w /1 At OWER
N 'S ANA : J / PJ��• V r`Y
POWNER ADDRESS TEL FAX
0 J/;2' TYPE OR OCCUPANCYTYPE COMMERCIAL❑ EDUCATIONAL 0 RESDSI'li AL❑
/ PRINT
CLEARLY NEW: RENOVATION:❑ REPLACEMENT:0 PLANS SUSMI t I tU: YES 0 NO 0
FIXTURES 7 FLOOR MCI 1 I 2 I 3 I 4 5 0 7 8 9 j 1 D 11 I 12 13 14
BATHTUB I I I
CROSS CONNECTION DEVICE I I I I I I
DEDICATED SPECt%WASTE SYS I I I
DEDICATEE)GAS/01USAND SYS I I
DEDICATED GREASESYS I I I
DEDICATD GRAY WATER SYS I I I
DEDICATED WATER RECYCLE SYS I I I
DRINKING FOUNTAIN I I • I
DISHWASHER I I I
FOOD DISPOSER I I _I I
FLOOR/AREA DRAIN I I I
INTERCtritOR(IN'FRIOR) -I I I •
KITCHEN SINK I ) I
LAVATORY--.
L
ROOFDRAIN' I I• I
SHOWER STALL
SERVICE]MOP SINK • I I I . ' i_____ I
TOILE i
URINAL 1 I I
WASHING WACHINECONNECTION II I I
WATER HEATER.AL TYPES II
WATER PIPING ri.-----rI
OTHER
I
I II II E I .
INSURANCE COVERAGE:
I have a currant liability Insurance policy or its substantial equivalent which,meets the requirrmen5 of MGL Ch.142 Yes No 0
IF YOU CHECKED YES, PLEASE IND1CATe I E OF COVERAGE BY CHECKING TI-IE APPROPRIATE BOX BELOW
L.IASIU1Y INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND ❑
OWNER'S INSURANCE WAIVER I am aware thattha licensee does not have the insurance coverage required by Chapter 142 of t
Massachusetts General Laws,and that my signature on this permit applica5on 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
best of my Knowledge and that all plumbing wort and Installations performed under the p it issued for this application will be
compliance with all Pertinent provision of theMassachusettsState Plumbing Code and C 42 of the General Laws.
PLUMBER NAME; P//Mf C� ,3 1 Q t/LO s SIGNATURE
Ai LICit i4• b IJB�JP�RPO TION ❑$ PARTNERSHIP 0 A t LLC D$
COMPANY r `. Z( 4-1 ADDRESS z cA Kir Ho V`/ )4 b -
CITY 9171-112-40001.4� STATE/M ZIP��2 d u
TEL J "D 3c `�"Iq 3 CELL - (; C t o�t EFAX"r 1 •
• JUL 21 2011i
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ROTJGTi PLUMING INSPECTION NOTESTTTTS P'. OP OR TNSP I CPOR ME ON V
pit tiro 0:14,241-47J/'SYee No
. s : : 4: 81 sat _ :t„t ❑
FEE: $_—______ PERMIT fl_—______—
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