HomeMy WebLinkAboutP-14-792 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBINGWORK
Sail SaCIN OYWI0 V)• MA DATE (r7 ei/ PERMIT# PH- 7Wz
JOBSITEADDRESS 7 Vtvlt4tGvt Ar OWNER'S NAME /Mke 6o/dock-
OWNER ADDPFsS
o/drocic`OWNERADDPFSS 45/1- TEL FAX
TYPE OR OCCUP.ANCYTYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDcBJT J �,[
PRINT
CLEARLY NEW:0 RENOVATION: I REPLACEMENT:LACEMENT:❑ PLANS SUBMITTED: YES 0 NO u`
•
FIXTURES 1 FLOOR 1 BSIT 1 I 2 3 4 5 I 8 7 1 8 9 I 10 I 11 I 12 1 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYS I I
DEDICATED GAS/01LISAND SYS I I
DEDICATED GREASE SYS I I I
DEDICATD GRAY WATER SYS I I I I
DEDICATED WATER RECYCLE SYS-
I I I
DRINKING FOUNTAIN I I I
DISHWASHER I I I
FOOD DISPOSER I I I
FLOOR 1 AREA DRAIN I I I
INTERCEPTOR(INTERIOR) I I I I •
KITCHEN SINK I I I I_
LAVATORY
ROOF DRAIN"-
SHOWER STALL
SERVICE 1 MOP SINK •
TOILET I I I I R F C FI! !! 11F0
URINAL I I I 1
WASHING MACHINE CONNECTION I I I 1 1 1
WATER HEATERALL TYPES I I I II,"I 2Q1)1
WATER PIPING I I I1 I
OTHER
1 1 I I u' u
I I 1 1
• • INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equlvalentwhich,meats the requirement o .I1 �-7 t
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THEE APPRCPRLATEE`BOX BELOW—
LIABILITY INSURANCE POLICY OTHERME OF INDEMNITY 0 54114X10 Wfif
OWNER'S INSURANCE WAVER lam aware that the licensee does not have the Insurance cot era9e required by Chapter 142 of th
Massachusetts General Laws,and that my signature on this permit application waives this rend
CHECK ONE BOX ONLY: OWNER 0 AGENT U •
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information 1 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 Cha ter142 of the General Laws.
PLUMBER NAME cid cI<
T KOIn< •
SIGNATURE,
LiC# aY1 SS MP JP[f. CORPORATION ❑# PARTN 9* LLC ❑#
COMPANY NAME JO ck (6 n C- ADOF: 3 1 hl on a may 4'° •
CITY S y a Ir1M STATE MCI ZIP 0.4-66q
E1u AIL
TEL 1 6-6 e - 39 9-0.2 gats FAX
c..e 11 0 5' 6 ?S-S`6 S'.6
/7/21/-
iNSPUCTTON
ROUGH PLUMBING INSPECTION NOTES FINAL OTES
THIS PAGE POR INSPECTOR USE ONLY
Yee No
. S :' C ON RYES.9 -i I ❑ ❑
FEE: S_-- PERMITiI_��
nt ANUEViRW N0—FS
1