38A-062 (4) u:4j HM FK WEb!ERN EU I LDERS I NC467 9559 TO 5352486 P.04
City of Northampton Departamt of Publk Works
Dhd =of Water Supply
- 125 Locust Street
Nortl,a mpto*MA 01464
..j3addlow Prcm ion Device Design Data.Sheet Application for installation
ownees same r"w'► !T'?r1 C.'O "�`j�..a5
Add �'�;--
Telephone number sbls
- t
1��Vt
ltaeility►
Name— 1114 Lb&&Szz
Address ^ i
Contact perso
Telephone-.number of faci�iiy cc�n#a# n p —
New facwty EXiShng r
CYCnad description or the fmd of the iron of a;back(tow device—
Device Data
MaAlla tuMname Vj Ike r, No. 3Sd (ir-
RPBP or a QM*Valvea „ Sine
Hot or cold water unit_ — By-pass lyes az No_I�
Exact location of device t,�l'a r�rr L
Wkw usage down stiram,af device `r < ��
Gate valve: ]Baia valve utteraly valve
Plans and Sparc Parts Required
The instatlaziero cuutraor is rnr►asibte for MWgWgjt g space tubberi_ft for each device
A felly Wxicd,deMdead Wwwa tic of the potable and nplt potable wake'piping MMd&h ymmdin
the bacicSow pmvexxtioa device installation showing:
1. Heigbt above floor of dw device
2. Dist nice ftm waII of the device
3. Type of chemicWs)used(if any)and the:type of equipment upstream,and downstream of the
device
)lige noteKodc:The schematic drawing most be at least 8 K by 1 i inches with the following
infinmation in the oomnI„ttod fi to bloc/^k�.
Submitted by. C)a v• i"` �L�a�S'�
S ► ` Lb's sign atuce: ^~�.
ms's license#:
Ownertagent signature:
Date: -r 110(O i
All informMtaion listed above must be ic,ciuded on schr�tz,atic drawinat. xn atddition.a fee e►f SGS.t}Qt
made aavabte to the City of ftthamnton for each device aooliation mu8tbe submitted to thg
D.P.W.before ami appfieat3oca milt be processed AA t form the,plumbing inspector may be:
necessary for the installation of theca devices.
Approvals or denials of this apptica ion will be Mt dkegxiy to the owner_ if you have acy questions,
please call the Department of Public Works at 413-587-15'70.
Official Tll?'Yt+use only;
Alyp><ti Denial:
* TOTAL PAGE.04 **
„—,UL Ob dUUb U:4j HM i-R WESTERN BUILDERS I NC467 9559 TO 5352486 P.04
City of Northampton Di ed of Public Works
Division of ater Supply
125 Locust Street
Northampta,MA 01460
)�addlow Prevention Device Design Blatt Sheet Applleadon for Installation
Ownezas same ry► l+-t A C ZM24
Asa r6.06ver
Telephone number I .»
Facility �^
• Nairne —~ t+y► �'T1-�' �
• Address """_” t 1°�'I.�4-,
Contact perso r,i
Telephone number of facility coated person it Now facility. Existing
Genesi dasc iPoonfor ffi�.meed of the installation ofa4 w device
CZE
Device Data
Maonfacauearname Vj VIeG-
RPBP or le Chak Valves Size
Hot or cola water unit -passYes or No
E location of device t,.fc a � f-irA"c I
water usage down st=m of devicA r e .,, r,
Gate valve Dail valve uty valve
Plans and Spare Parts Required
The itestallaft le tbr setp bbA a spare robber»arts Mt tar each device
A fuuy labd4 detailed schematic of the potable and non-potable water piping immediately m4yundina
the backilow preventiva dovice installetion showing:
1. Height above Door of the device
2. Distance ftm wall of the device
3. Type of chemleWs)used(if any)and the type of equipment upA=nl,and dowv=eam of the
device
teftdc:The schematic drawing must be at least 9 K by I I inches with the following
Information in the aaGmpleWd title block.
Submitted by' Oa,"
signature: ...—
S ]hr's t si se#: 1d O��3�"'—
towner/a8ent signature:
Date: 17
all information listed abaye must be included on schematic drawing '1n addition.a.fee of$65.00,
made namable to the City of aurthan,p on for cub&,wipe application must be submitted tel the
RX-M before env amrtea on wilt be orocesse4 A permit farm the plumbing inspector may be
nemsaxy for the'installation of these devices.
Approvals or denials of this application will be sent directly t4 the owner_ If you lave arty questions,,
please call the Department of Public Works at 413-587-1570,
Oflidal DPW use only.
Approval: Denial,
* TOTAL PAGE.04 **