18D-040 375 King St �001-71dl? 31'5-) 00
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY NORTHAMPTON MA DATE 12-17-2018 PERMIT# �
JOBSITE ADDRESS 1375 KING STREET OWNER'S NAMEPRIDE
P OWNER ADDRESS 246 COTTAGE ST.SPRINGFIELD,MA TEL 413-737 6992 FAX 731 5852
...................______V 9_.
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ® RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES NO
FIXTURES Z FLOOR— BSM 1 2 3 1 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE F=EE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR INTERIOR
KITCHEN SINK
LAVATORY 3
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK Inspe, ion
TOILET (M
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING 1
OTHER
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 0 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 complia�ll Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME JOHN DALEY LICENSE# 30293__j SIGNA E
MP ___ JP `� CORPORATIONS# .::]PARTNERSHIPE]# =LLC #[�
COMPANY NAME ADDRESS[9-C BLANDFORD HILL RD
CITY1HUNTINGTON STATEF—MA—j ZIP 101050 TEL 413-336-6063
FAX CELL 413-336-6063 EMAIL JOHNKDALEY YAHOO.COM
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