HomeMy WebLinkAboutP-20-1345 ARP: Pl91ee6C ,
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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•_'I'_ CITY lcl(ztAi,t)V MA DATE etilokci (PERMIT# 640n-;10-40 1,9g
JOBSfTE ADDRESS Z ci ii5\-fri t-aCM Q-Q Nia-T11 OWNER'S NAME iM%KQ cc;dvtiN+n
P _OWNER ADDRESS I TEL 5-e8 Zqi 0 c -zi IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0
PRINT PLANS SUBMITTED: YES❑ NOD
CLEARLY NEW: RENOVATION:❑ REPLACEMENT:gi
FIXTURES Z FLOOR-0 BSM 1 2 3 4 5 6 7 8 I 9 10 11 12 13 14
_
BATHTUB _, � ,__. t- — � ,- - II
CROSS CONNECTION DEVICE ;,!■�- —. -z
iI .,ra 1
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DEDICATED SPECIAL WASTE SYSTEM — _- -++__ . h L_
l.,,_ _. -� u-a
DEDICATED GASIOIUSAND SYSTEM E -_ ' - ,
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM '. �' i 'I
DEDICATED WATER RECYCLE SYSTEM PL I! �. . _ L i — .Ai. I I
DISHWASHER -
DRINKING FOUNTAIN I `' L ".
FOOD DISPOSER I - �_- 11
FLOOR FLOOR/AREA DRAIN 2 _
KITCHEN SINK L
INTERCEPTORK(INTERIOR)
LAVATORY __._ _. J -• ._1 —
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK I U.'
- `I
_
TOILET '' � _
URINAL i L 1
WASHING MACHINE CONNECTION ---
WATERHEATER ALL TYPES -_ , II mi,
,I ,___
WATER PIPING I' I
OTHER __ _ i. _ ` _ I ii. i'11
I
JI ,- L
• INSURANCE COVERAGE: `k� -.. ..
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. "YES"t.( NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ' a J L I } `; `:1
LIABILITY INSURANCE POLICY b OTHER TYPE OF INDEMNITY❑ BOND ❑ s (}� . a- V
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required iy 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
ofmy knowl
the edge
and that all plumbing work and installations performed under the permit issued for this application will be in comprian --. -
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Massachusetts State Plumbing Code and Chapter 142 of the General Laws. . /
-PLUMBER'S NAME )IM K S' ITA V I N I LICENSE# /S 97 9 I ' RE
MPgi JP CORPORATION❑#{ IPARTNERSHIP❑4 ILLC❑#
COMPANY NAME IS JA.K C,'T4 )u 016 ilk)it I ADDRESS 1& -I 4 Le I tv
crtYj(VI t,, )-Dv r ✓l,,1 k5 ISTATE 1 iAl/ I ziP l oZ I/`q I TEL "�--3-9 7,0 / 3Z,k I
• FAX I 1
0ELL L =: 1 EMAIL 6'A V t /�N I 0 l'y CY '4;L . (9.41. I
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ 0
FEE: S PERMIT#
ELAN REVIEW NOTES / /‹-t
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