HomeMy WebLinkAboutP-20-3045 ''° 0,
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MASSACHUSETTS UNIFORM APPLICATION FORA PE- 1 TO PERFORM PLUMBING - -
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A_,_ CITY �6c/yN t'/ Gj MA DATE /1 -2 S--/9 PERMIT#lkGOP7R0 Y!C cr9 "
JOBSITE ADDRESS / T .'i-1 G. OWNER'S NAME 9, • r`2 S '
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0
PRINT
CLEARLY NEW:0. RENOVATION:❑ REPLACEMENT:[ — PLANS SUBMITTED: YES❑ NO 0
FIXTURES 1 FLOOR-, 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/0IL/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 -
j LAVATORY _ _
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET - - -
URINAL
. WASHING MACHINE CONNECTION •
-
WATER HEATER ALL TYPES j
WATER PIPING 6 / - -
OTHER
• INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of M F* -,. ' .4M. %i V. r
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BEL'W '"- `"`- ' _'_._.__1
LIABILITY INSURANCE POUCY OTHER TYPE OF INDEMNITY 0 BOND ■ NOV 25 2019
I OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage req it •. v,i�,.��j,�,_1, f'
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Massachuse eneral Laws and that my signature on this permit application waives this requirement. lay ri / >, _
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SIG CHECK ONE ONLY: OWNER El AGENT 0
TU OF OWNER OR AGENT
14.1 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 with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. P.P--f<
PLUMBERS NAME UCENSE# /1 . SIGNATURE
MP JP❑ jj CORPORATION El# PARTNERSHIP 0.# LLCTit
COMPANY NAME l t v-(' j-I ADDRESS 70 54431
46
CITY P". STATE I/14 4 ZIP 0 Z 6 Y (n TEL c" , '7 O 2 V2
FAX CELL EMAIL /
UC14
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ /� �i�Zy ,0y4 ,G '
FEE: $ PERMIT#
PLAN REVIEW NOTES •
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