HomeMy WebLinkAboutP-20-1979 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
yam, / I(� / c,/CITY l�("14,0° " ` MA DATE ! D! / PERMIT* e -15/v/q
JOBSITE ADDRESS 2 9 6 rah - frV f ( JU ► OWNER'S NAME I /LQ f)-A..L -4/
OWNER ADDRESS TEM Z156 f 2/ FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:.] PLANS SUBMITTED: YES❑ NO El
FIXTURES 7. FLOOR—r 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/AREA DRAIN -
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
I SERVICE/MOP SINK OCT ( '9
' TOILET
URINAL
j WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESt NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [ '' OTHER TYPE OF INDEMNITY 0 BOND 0
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 ' ertin ovtsi of the
Massachusetts State Plum ing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME CM-4S L-#14A u LICENSE# / ' '' ' GNAT RE
MP( ' JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME St if C T(( P/v ill jj,A)O /iGL ADDRESS Ste/ Lp.�� 61-
CITY 1' t €t I rvST0b STATE ZIP 02(p(6 9 TEL 7/ Z(2 /3 a
-C'FAX CELL EMAIL -AtV ttki /O ® G' /� I�G , C_9 1
C.D4r313ALC-17-1-RtP
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT# FcnV/1-6- d
PLAN REVIEW NOTES t-ght. 1 /5-h
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