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PARCEC :
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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n;,'"=,4 CITY 7`'0/ Q/.) _. 1 MA DATE 21'0/-i7_J PERMIT#/'1i/JP l?- 'C'0 c /3
t JOBSITE ADDRESS T1,2_62 L.1) KN_f .•___J OWNER'S NAME
POWNER ADDRESS ILL JQffY1OutJ1 9 TEL AX
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUC ONAL D RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION: EPLACEMENT: PLANS SUBMITTED: YES 0 NOD
FIXTURES 7 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB . _Al__.,.....:..11..�= L..11..._.y.11__ 1I z (..�. ._1 L___ _-„_.,_.� .. ._..__A
CROSS CONNECTION DEVICE 1.. �_,«.-_ I=a�u ,.s l_.a_._l.s.._IL:x__.11_-.-_-J(- - . I— =1-- ._..1i_ JR.�, L.
DEDICATED SPECIAL WASTE SYSTEM 1 _I(Q, �, I„,._ „�Ir IL_ .�. _ IL�1 JI� I� .11 ,I L____1h...�..,..1=4
DEDICATED GAS/OIL/SAND SYSTEM 1_,,,..i1_,ii_.-__ 11 _al__ ._11 , I, m,___11 __ 11._ =1_.__I1 ,_( 1
DEDICATED GREASE SYSTEM L_,. 11 _ -_I _IL_ _1_ I'_,.�_ ��s,_�11 �,-,�., u� , ..I _� IL : 1__ � � ..�;«
DEDICATED GRAY WATER SYSTEM � .1 �,„. ,_ 1___ I L w.-I_ _,, II s L _J .4i_
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DEDICATED WATER RECYCLE SYSTEM 1 _...._ t _. i. ..__._ iL _-1I_e_....tb.,._11_.. ,,._II . _.IL _.. 11 . .L -71L__.... I
DISHWASHER L _:i'_= i`. 11___11��." i1,,�,,. 1� ���,...4'�_ I i.== �� .,.�IIL .I_1
DRINKING FOUNTAIN I ! 1i IL 11_ 1 M$77-1L _ .17-1' 1 .1 1 R:1
FOOD DISPOSER I 1 L II__i-:. � 1i�-�,. .i-� -9L,. x,�- 1__m�1�._�.,., 1 =1_. 1
a ��
FLOOR/AREA DRAIN 1 L J1, IL:-__ i .....,._J �. 1 ,�..I_ 1 _ 1,1_.__ I__�,...JI ..y 1.�_
INTERCEPTOR(INTERIOR) L. _� t1 91 __ 1^] . l _IL a,.,J1 _,_ .1 ___ _ z' _=1IIIIII
KITCHEN SINK L_-_,,,T/d__ __ '.__� i� 1. .:.''.__ . f,.� ��L L1J .�
.' ,y L ,. ___
LAVATORY I_..,, IL L-
fI 71_r !1 __ I _i �,� 11011_111 .
ROOF DRAIN 1< _. _IV 1 _J�5 I_� .� 11� �_{ ,..I ._�11 .I1.�� 11���11 1.,_...n�,. 1 1��J
SHOWER STALL ,..�?r „F i___ .1 _1 „1!- 1p.,._.11=, _„Ii__ I= ., ...��=a:.�,.�:I ._m..11.. 1
SERVICE/MOP SINK I—I j �1j L i ;I )1 11 1 ___IL_ _____.1 s_
TOILET IC I 1# L. Jr L '.� 'I ii L _¢I - _ '` k __ -
URINAL ;I z,_„11 _ 'L JI,.. J1m�_1 '1 1I. � L�__ t - 3
WASHING MACHINE CONNECTION I I1 { . � ) _ 11 _ 4 }1 1 :I_ i1 _ I.__,J1 ____.1..��_____.11 `.-1
WATER HEATER ALL TYPES 'm a ' ._IL�.___IL_r.�.11__ fl �,217_ L .. L n.___JL L>-....,., _1_11. . _...__.0..1
WATER PIPING L. toe I J. .s1 :91 ____11,., _11e. _11___Ii__._ ._I i___ _I I._.._.. _ _::.
OTHER 51�� i�.�_.>,. `. �_pl�_._,1_..a a _ _1 1 II_ L�II_ v_.. FL
II 4 i
i .8L 3L.ev.�JL 1 ..,.r73' _..__. �'_--"°",.I Y _ II L_ 1i ._..,.,......1 -__ _I
1.��__ _:_._..�_ _..�..�-.� _ _ - 11 _1 _II ,I_ d, IL I I i I
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 10 0
IF YOU CHECKED YES,PLEASE INDICATE THE PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ' OTHER TYPE OF INDEMNITY 0 BOND U
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 0
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 t of my kno dge
and that all plumbing work and installations performed under the permit issued for this application will be in corn- P ' ent visio he
Massachusetts State Plumbing Code and Chapter142 of the General Laws. .0.
PLUMBER'S NAME ; j J CCCA.,_ LICENSE V42hzzaj .- SIGNATURE
MP JP[ CORPORATION IJ# yJPARTNERSHIP[j# _ 1LLC0# _
COMPANY NAME y �j �p
I 'Ly1 7'G�l["I/��. YI `I' Z1. �(
7 , ADDRESS o .. re�IC'f:. i
CITY n r_
te .J,/ Lv __ ._.._J STATE �'1CL,.d.l ZIP (AZ( 02.' TEI.L..Qg:. 1.96__:-6t.R.L__.
FAX CELL EMAIL . _ t
Ova `1?�;,.� ' �3 _....-�_.�. ,____..... . __.,.y.. __ .__�.� ___ _ _I
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT El El
FEE: $ PERMIT#
PLAN REVIEW NOTES
4
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