HomeMy WebLinkAboutP-20-1892 Qirfifit Pv r• co///tot,
MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM PLUMBING WORK
_1 - CITY (A! .7 /42 MA DATE /b/7l"c} PERMIT#/ D— '�/g7Z
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JOB SITE ADDRESS �y A-lI/S O.v � OWNER'S NAME /►'� A A
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL,
PRINT
CLEARLY NEW:❑ RENOVATION: . REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7- FLOOR--I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB _
CROSS CONNECTION DEVICE _
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER _
DRINKING FOUNTAIN
FOOD DISPOSER _
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR) _
KITCHEN SINK
I LAVATORY
ROOF DRAIN
c fiCT
SHOWER STALL .
' SERVICE/MOP SINK
\J' TOILET
a
v i URINAL _
WASHING MACHINE CONNECTION •
WATER HEATER ALL TYPES
NS WATER PIPING
OTHER .c7 y-) c C464- r, j
•z i INSURANCE COVERAGE:
0 i I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESV NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND ❑
OWNER'S 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 ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR 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 of y knowledge
and that all plumbing work and installations performed under the permit issued for this application will be incomplia e with all •n t ro ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
(PLUMBERS NAME r ;ra'i CIA(1/_E LICENSE# 0 ATU E
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MP [ JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME iD • C/4)4( 1k)E ADDRESS /3 7 fi M R F'`j s 7-
CITY e , et e STATE ,r1/1 f1- ZIP r)r2 6 `// TEL 5-6 '2 9V— -3 6f
FAX CELL EMAIL
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT It
PLAN REVIEW NOTES 0}- �-�-
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