HomeMy WebLinkAboutP-20-1662 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY (DA6�n"' MA DATE ( ,,e? 5 4, 1q PERMIT# Mee'-0D/(662
JOBSITE ADDRESS 6 L U°VYj6 4r OWNER'S NAME
OWNER ADDRESS 5441V2 TEL FAX
TYPE OR OCCUPANCY TYPE COMMER IAL❑ EDUCATIONAL ❑ RESIDENTIALPr---
PRINT
CLEARLY NEW: ❑ RENOVATION: . REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR—I 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 Fl
FLOOR I AREA DRAIN }®' L y
INTERCEPTOR(INTERIOR)
KITCHEN SINK ) 5Ef 2 u 20.('
LAVATORY
ROOF DRAIN ?
SHOWER STALL 1. `
SERVICE 1 MOP SINK
TOILET
URINAL
. i WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
i
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 POLICY 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 compran with all Periinen provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME JC ('e) W t fi Pil/ LICENSE* J0, 1 (� SIG ATURE
MP[114 JP❑ CORPORATION[1 PARTNERSHIP # LLC❑#
r ' 919 �; ��� &t64 AGA
COMPANY
� NAME � �tr�l,_Q (�r u�V(,1� )��G(/ ADDRESS / �/ t'j, I/
CITY J i Q�r 11C& �` STATE TAG, ZIP (0) �lo `7 TEL o j�?'2j)73 6 t
FAX CELL EMAIL i O rVe )).2 ( t C
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ 'J fr
FEE: $ PERMIT#
PLAN REVIEW NOTES
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