HomeMy WebLinkAboutMiscellaneous - 93 ROCKY BROOK ROAD 4/30/2018 (22)MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY . near NZ�Q_y ._.- _ ._ it MA DATE 12. - PERMIT #
JOBSITE ADDRESS CU�_Q_.._.il OWNER'S NAME . /fP..............D._r_Pc<
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OWNER ADDRESS -- _..._...__.__ _ _._4.._. - - _ _ TEL __....._T - .. --i FAX _...__ ....._...
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TYPE OR
OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL Ej RESIDENTIAL EK
PRINT
CLEARLY
NEW: El RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES. I NOD
FIXTURES -1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUBI ....___. _ i ..... ........i ...__...... ---- ..___-_ I_M._......... ...-..,.....:..., __.,.-.I ._..-._..,....:) �_--._. _......_..__I ,...........•_l ______.
CROSS CONNECTION DEVICE _-.__I ._.._.._.:_I ._........ i :.-_._I ,---.1 ..__.__� ._._.._I ._,-:... .:___..i -,---• __I ._._...._I .._.....I .....--I _-_ -I __._.
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOILISAND SYSTEM __.- ..........:_...! ..:.:__....( �- -_-.-_--._! ......._.-.._-I _..___. I ,,.:....:-.-.. ._:._-•.i ___-! .___._l .._..... -- _ I -__--_--.
DEDICATED GREASE SYSTEM __-_J ___.M__i __..._I -___J _-- __1 1 I ..._..- _—__-' ----...-.._I .............I ._.__.-- .___-_-I _..._._._.-_J
DEDICATED GRAY WATER SYSTEM ' ._ ..............1 _... _-_.i _ __..._....._.. ___J _......__.- _---___---.--__—! _._.-- —-_............------ ._--_J
DEDICATED WATER RECYCLE SYSTEM ----..-_-.! _.._...._._.i ._.—....._._I
DISHWASHERI ..................I ....__-( __-- .- .--_.__.1 ..-...,_....._I .___ . ___..._...........:.... ._._..-.__J .._;___..I .........._..._..I .........__J _ _.._ I .___._.__E
DRINKING FOUNTAIN
FOOD DISPOSERS......
_.
FLOOR/ AREA DRAIN _I . _...__._J .__....._._l ___........I _..--__I ..�_....! ._.._._.....,.I __._....._ _..__._...` __.--__,I ..........._ I -�_.....__........................1 _. __I
INTERCEPTORINTERIOR --_.____! .......__.......1 .......---_._.... -..,....._._....._..__-....._-.,_.i __-_.-.: _...._....; .....-____-. _._-__! ._._......................... i .__,.
KITCHENSINK ! ----I _ J .... . _I ..._... - I - -t ..__..__ _...I .-.....__ .__._. -a _......_....I ...-....__......J - - ........_. _..._..._ I ----!
LAVATORY
ROOF DRAIN
SHOWER STALL _ ..� ...... ..... ...... f ......_.__ .-___.._._....__....._.._...1 ..,..._ ..' - :._.__...._.........` ....__..-1 ._.._._... _......._._.._.. - -
SERVICE /MOP SINK _I ... .._-.I - ... ....:... ...( ...... ..------..._i ........._.--.' ..... _...__ .....__._._ -.. --
TOILET --------
URINAL
WASHING MACHINE CONNECTION._.__.-_.. r�..l .._.:....::..:.........; ......_-,._': _•__._..._.'s ... _..:._
WATER HEATER ALL TYPES -.
WATER PIPING _
OTHER-
- ..........._...._..-.._..__...._-....... _ .......................... --..._...1 _ -.. _..! _.......... I ..... 1 I .. _ :.......I ..........._..1 .._. -I -_ ......._ .......( ._..._.__I ....__._I ................3
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INSURANCE COVERAGE:
I have liability insurance its the MGL Ch.142. YES B"NO [.
a current policy or substantial equivalent which meats requirements of
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: OWNERE] AGENT ...._I
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 a d urate to 1 est of my knowledge
and that all plumbing work and Installations performed under the permit issued for this application will be in oompjl tYat t vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General laws.
PLUMBER'S NAME ?l 1.�_ ..,.i9/_- C3QG,CJ LICENSE #��'�'9� SIGNATURE
MPV JP[3 CORPORATION[ PARTNERSHIPE1#[77LLCD#
COMPANY NAME SW ADDRESS
CITY I STATE ZIP TEL :
FAX L=CELL �^ EMAIL _ I
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