HomeMy WebLinkAboutP-20-1504 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
--" CITY w1.041\ MA DATE t li i 1 l PERMIT#/g-Y!/VOZ9/5I y
e k.4 .. 1
JOBSITE ADDRESS 2� 6Cal �s;M S'� pvOJ� OWNER'SNAME
G (
OWNER ADDRESS TEL !7Z FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: Zf • PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7. FLOOR-+ BSIv1 1 2 3 4 5 6 7 B 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/AREA DRAIN _ _
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE!MOP SINK
TOILET URINAL SEP
1 Z
. WASHING MACHINE CONNECTION •
WATER HEATER ALL TYPES j
WATER PIPING vC
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESK NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY p- OTHER TYPE OF INDEMNITY 0 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 best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance wi e ' e 'on of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
� r
PLUMBER'S NAME 0"45 brt t4-/ LICENSE# /5 9. SIGNAT E
MP ►.41 JP❑ CORPORATION❑# PARTNERSHIP # ❑#
COMPANY NAME E-{,Q- 'k CfT1 P/(I+M 40f,-- ADDRESS f fp M Zq IA
CITY /Vl 4 S`i v]7,0') ✓rk' 05 STATE °1/04- ZIP CZ if E y TEL ?� Z/2 / f.
FAX CELL EMAIL `7"E CT tI ):00 " C-0`M
O- 31) sr-0--
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT U
PLAN REVIEW NOTES
4-1-20/67//'
I •