HomeMy WebLinkAboutP-17-1175 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
5 CITY Ycve r►n•v MA DATE 7/6 r 2-0/ PERMIT#/94-0P17 V/17J
JOBSITE ADDRESS `I D Fski vi 1 &ry up ge./• OWNER'S NAME Gr v14n
OWNER ADDRESS 410 F; s lv;‘, Sri) is P4. TEL FAX
z 6 7•b y 7b FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL F]
PRINT
CLEARLY NEW:( j RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7 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/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM _
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
E,CHEN SINK
L'X"/ATORY 2
I 'tl;OF DRAIN
SOWER STALL
3SRVICE/MOP SINK
trIET
I ,URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING I
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES( NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY OTHER TYPE OF INDEMNITY ❑ 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 with all Pertinent provision of the
st Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
w PLUMBER'S NAME L&r!'cw/ . CA•vuerr�v, LICENSE# /6/7 S. SIGNATURE
MP V JP d CORPORATION❑# PARTNERSHIP El.# LLC❑#
COMPANY NAME CG,i N�vri om eir2,1S0-fv ceS ADDRESS 69 SeSL,!f I'Jc.ek
CITY £ • Uevtw/S STATE MM ZIP 026 '/ TEL 71 y •z/Z •2o?r
FAX CELL 77/•2t2 - ZU?S_ EMAIL eDc k Ct'vi
ROUGH PLUMBING INSPECTION N TE BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
fp6 f�G'6 'C c-/7/71- .'lb /4 Yes No
THIS APPLICATION SERVES AS THE PERMIT El ❑ ._,
ee( 0 LA F7- MA//(/FEE: $ PERMIT# / *
PLAN REVIEW NOTES
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