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HomeMy WebLinkAboutP-20-2941 M_ ASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK '; j_ CI It ``^0 vit 1 MA DATE 11' I9- 1 I PERMIT# —q2 rq JOB SITE ADDRESS,1- LJA 14)5 grODk 9-9' OWNER'S NAME NM' J:J'i r-fil' POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW D. RENOVATION:❑ REPLACEMENT:U27. PLANS SUBMITTED: YES❑ NO 0 FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 7 li 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEM - DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM --- DEDICATED WATER RECYCLE SYSTEM DISHWASHER • DRINKING FOUNTAIN FOOD DISPOSER FLOOR 1 AREA DRAIN INTERCEPTOR(INTERIOR _ KITCHEN-SINK' v(et- ( €' j LAVATORY h ROOF DRAIN +-- I3 1 yi•� ! y Al _ SHOWER STALL I 1/.,. I I SERVICE/MOP SINK r TOILET t� URINAL ..dam T WASHING MACHINE CONNECTION 1 WATER HEATER ALL TYPES L WATER PIPING OTHER _ • INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES INO 0 IF YOU CHECKED YES,PLEASE INDICATE THE E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW .,, LIABILITY INSURANCE POUCY 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 0 AGENT 0 SIGNATURE OF OWNER OR AGENT 141 I hereby certify that all of the details and information I have submitted or entered regarding this application are • �.• � and that an plumbing work and installations performed under the permit issued for this application will be in co• . . !g!M� te to the best of my knowledge Massachusetts State Plumbing Code nd haWe General Laws. ', • ''of the PLUMBER'S NAME��1�1� £e\ � 0 c� LICENSE#132(0 J SIGNATURE MP JP 0 CORPORATION 0# PARTNERSHIP❑.# tic 0# COMPANY NAME C OE .2+ M51114O t-4eigilb WpDRESS (Of 5(7J(7 CITY STATE OA.14 �2 ZIP TEL�� C`1 7 7�'E71 I FAX CELLLC 9 Z2') 2-0 EMAILCct e f l N.)"‘DI 4 r 5 t''2<+I!1cj d .5y,sr4i f,Cbm c16 [('3 C)r- ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No D THIS APPLICATION SERVES AS THE PERMIT 0 0 J FEE: $ PERMIT# /4e)a -. 7. 111/1 /et .5' 46, PLAN REVIEW NOTES -f-441A/Y) P/-6 i kI+ 4 h; . . • i . . . 4 ,..,_