HomeMy WebLinkAboutMiscellaneous - 93 ROCKY BROOK ROAD 4/30/2018 (23)MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY /R `
..-_..�_,��.�...p._lL�_ ._I MA DATE 2 -� _ /Z _� PERMIT#
JOBSITE ADDRESS �,�_ /1! Gley �noo„� ��j OWNER'S NAME
OWNER ADDRESSoc�'/10 p e�C/- _ TEL 2 FAX {,
TYPE OR
OCCUPANCY TYPE COMMERCIAL 01 EDUCATIONAL E11 RESIDENTIAL
PRINT
CLEARLY
NEW: RENOVATION: [3-4 REPLACEMENT: M PLANS SUBMITTED: YES NO
FIXTURES'l 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 GASl01USAND SYSTEM i (-_._._._ i _...... _!
DEDICATED GREASE SYSTEM _ __.
_ _! __...._ t _ ._ ..f __. ! _....._...__! ..._...._.!
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM !
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN _ .._i ....__.. iIL.___i ....___1 ____ [ I _..__ J -_ ! ._. __-......_i ... _I
INTERCEPTOR (INTERIOR
KITCHEN SINK _I
LAVATORY_.._ -------- __. I .._.__._ ( _.__.__ !
ROOF DRAIN
SHOWER STALL...____. I
SERVICE I MOP SINK _..-_-.__! ,_.__.-_.__i _._..____-_._.—i _.. __.__i .___._.__.i _..----i--......__I __.___! _---_._E __ __ (._._ .--.-i--I
TOILET-_.i _..___.. ._._____( .-- --- ._.S __._
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING i 't .__._! _ .... - .� .
OTHER
e
r
INSURANCE COVERAGE:
1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO .._._
DF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY Ej ,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 10
SIGNATURE OF OWNER OR AGENT
10
B-hereby certify that all of the details and information I have submitted or entered regarding this application are true and ac t 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 ertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME,}'TeVe ti 6/Z I LICENSE # 4, ' SIGNATURE'
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li/IPg JP 0! CORPORATION 0# -_ _-- - _. PARTNERSHIP 0# = LLC -r I . f G „ /to
COMPANY NAME f�c Ly/1/ply Lf f�17h1 v_- i ADDRESS ,(a,
CITY �%yl�%V 1 •t<. -_I ZIP / y ; TEL
---____—------_-____ . _ _ .._. (STATE B._� _..-
FAX 9/08/ CELL EMAIL Lc �/
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