HomeMy WebLinkAboutBLDG-16-000105 1 � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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= s+= CITY Soc177-1 Yet u1QccT-f I MA DATE W :J5 ►S e PERMIT#/P/& /6S
JOBSITE ADDRESS t 1 I l ., -i1-1 — ` :0e I OWNER'S NAME Mk)t2 I-1 w .i,.-J i ;7
P OWNER ADDRESS I TEL£, 0-a5 c)3.3Z► IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALN
PRINT PLANS SUBMITTED: YES❑ NOW
CLEARLY NEW:® RENOVATION:® REPLACEMENT:NI
FIXTURES Z FLOOR BSM 1 2 3 4 5 6 7 8 9 I 10 11 12 I` 13 li 14
BATHTUB /
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM i'
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM 1 y
DISHWASHER
DRINKING FOUNTAIN
- 2
FOOD DISPOSER , _ .. r----
FLOOR 1 AREA DRAIN '.. _ 1
INTERCEPTOR(INTERIOR)
KITCHEN SINK y ,
LAVATORY
ROOF DRAIN lI
SHOWER STALL
SERVICE 1 MOP SINK
TOILET
URINAL I i }
WASHING MACHINE CONNECTION 1 i
WAT r 1
WAT9R �. ,
OTHER y
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T r INSURANCE COVERAGE:
I havc-a-curnIntitlibitRy insurance pokyor its substantial equivalent which meets the requirements of MGL Ch.142. YES Ei NO El
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY E 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 • Pertinent.provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Chris Briggs I LICENSE# 12901 I SIGNAT RE
Mp❑ Jp❑ CORPORATION LI#3238 (PARTNERSHIP❑# ILLC❑# I
COMPANY NAME Briggs&Heino Plumbing&Heating Co.,Inc I ADDRESS P.O.Box 538 I
CITY Centerville I STATE MA ZIP 02632 I TEL 508-778-0816 I
FAX 508-775-0404 CELL EMAIL rbrjhj@aol.com
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES -
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
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