32A-186 (7) 5 POMEROY TER BP-2018-0435
GIS#: COMMONWEALTH OF MASSACHUSETTS
Man:Block: 32A- 186 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: CONDO BUILDING PERMIT
Permit# BP-2018-0435
Proiect# JS-2018-000777
Est. Cost: $400000.00
Fee: $2800.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MATTHEW CAMPAGNARI 076047
Lot Size(sa. ft.): 15986.52 Owner: WINTERBERRY LLC
Zonine: URC(100)/ Applicant. MATTHEW CAMPAGNARI
AT. 5 IAC;MiER0 i T ER
Applicant Address: Phone: Insurance:
128 FEDERAL ST (413) 237-5872
SPRINGFIELDMA01105 ISSUED ON.2/28/2018 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONVERT 9 UNIT APT BUILDING INTO 6 UNIT
CONDOMINIUM - BASED ON PLANS DATED 1/16/2018
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
h: 9/ Footings:
Rou
g �� Rough: House# Foundation:
�q Driveway Final:
Final e/// Final: 7,�O
n�y� Rough Frame:
Gas: Fire Department Fireplace/Chimney:
I
L+b
Rough: Oil: 2
Insulation:
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Final: �� !BE
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THIS PERMIT MAY RE OKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND TIONS.
Certificate of 0 cupancv si nature:
FeeType: Date Paid: Amount:
Building 2/28/2018 0:00:00 $2800.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
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The Commonwealth of Massachusetts '
City of Northampton
Certificate of Occupancy
In accordance with 780 CMR, (The 9th Edition of the Massachusetts State Building Code)
this Certificate of Occupancy.is issued to the premise or structure or part thereof as herein identified.
Identify Name of Building of Space Within Certificate No.
Issued to BP-2018-0435
Winterberry LLC
Identify property address including street number, name, city or town and county
Located at
5 Pomeroy Terrace
Northampton, Hampshire, Massachusetts
Use Group R-2 Occupant Load
Classification(s)
6 Units
This Certificate of Occupancy is hereby issued by the undersigned to certify that the premise,structure or portion thereof as herein specified has been inspected for
general fire and life safety features. This certificate shall allow for the use as herein described and in conformance with any and all conditions as identified below. It
shall be posted in a conspicuous place within the space as directed by the undersigned. Failure to post the certificate,failure to comply with conditions or,
tampering with the contents of the certificate is strictly prohibited.
Conditions of Use Structural,Means of Egress and Life Safety and Sprinkler Systems must be maintained.
Yearly Inspections Required per Massachusettes State Building Code CMR 780 Section 110
Name of Municipal Date of Final Map/Plot:
BuildingOfficial KeV� ROSS Inspection 01/16/2020
Signature of Municipal Date of 32A-186
Building Official / Issuance 01/16/2020
Cit
J of Louis Hasbrouck<Iasbrouck@northamptonma.gov>
Fwd: 5 Pomeroy closeout
1 message
Louis Hasbrouck<Hasbrouck@northamptonma.gov> Fri,Dec 20,2019 at 9:53 AM
To:Matthew Campagnari<mattycamp@yahoo.com>
Per DPW;CO for 6 units will be OK as soon as the rest is sorted.The DPW can wait.
Louis Hasbrouck
Building Commissioner
City of Northampton
Town of Williamsburg
(413)587-1240 office
(413)587-1272 fax
---------Forwarded message--------
From: David Veleta<dveleta@,northamptonma.gov>
Date: Fri,Dec 20,2019 at 6:44 AM
Subject:Re:5 Pomeroy closeout
To:Louis Hasbrouck<Hasbrouck@northamptonma.gov>, Donna Lascaleia<dlascaieia@northamptonma.gov>
Cc:Carolyn Misch<cmisch@northampion ma.gov>,Jonathan Flagg<iflagg@northamptonma.gov>,Doug McDonald<dmcdonald@northamptonma.gov>
Louis,
I spoke with Donna about this.We are fine with COs for the 6-unit building at 5 Pomeroy as long as we can withhold the COs for the other units to maintain leverage as
we wait for the final as-builts,annual stormwater report to confum the system was designed as constructed and the license agreement for the irrigation system in the
ROW.
Thanks,
David
On 12/16/2019 4:55 PM,Louis Hasbrouck wrote:
Donna,
Thursday is fine at this point.
Louis Hasbrouck
Building Commissioner
City of Northampton
Town of Williamsburg
(413)587-1240 office
(413)587-1272 fax
On Mon,Dec 16,2019 at 12:58 PM Donna Lascaleia<dlascaleia@northamptonma.gov>wrote:
Hi Louis,thank you for asking.I am waiting on as-builts for the irrigation to be incorporated into the as-builts requested by Carolyn.Once
this is complete,Alan will need to write up a license agreement for the irrigation system.David is out until Thursday.Does this need to be
sorted out before then?
On 12/16/2019 9:50 AM,Louis Hasbrouck wrote:
Hi,
The contractor is closing in on finishing the 6 unit building at 5 Pomeroy.What do they need to do to get the first COs?
It looks like Planning Board conditions kick in after the 7th CO(see attached).
Dave;I attached the most recent DPW information I can find.Is there a later list?Is there anything specific that needs to
happen before COs for the 6 unit building?I think the sewer and stormwater connections got sorted last summer.What
about the sprinklers in the tree belt?
Louis Hasbrouck
Building Commissioner
City of Northampton
Town of Williamsburg
(413)587-1240 office
(413)587-1272 fax
ti
I --
( Donna laScaleia
Director
Department of Public Works
City of Northampton
413-587-1570
s
5 POMEROY TER EP-2018-0781
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Map: 32A
Lot: 186 ELECTRICAL PERMIT
Permit: Electrical
Category: WIRE 7 GANG METER FOR MULTI-FAMILY DWELLING
Permit# Electrical
PERMISSION IS HEREBY GRANTED TO:
Project# JS-2018-000777
Est.Cost: Contractor: License:
Fee: $260.00 PIONEER VALLEY ELECTRIC MASTER ELECTRICIAN 14301A
Owner: WINTERBERRY LLC
Applicant: PIONEER VALLEY ELECTRIC
AT: 5 POMEROY TER
Applicant Address Phone Insurance
PO BOX 178 (413) 532-6098 C- Liability, ODNA051912
FEEDING HILLS MA01030 ISSUED ON:4/6/2018 0:00:00
,,- 3I - yo��
TO PERFORM THE FOLLOWING WORK:
WIRE 7 GANG METER FOR MULTI-FAMILY DWELLING
Call In Date: Date Requested Inspection Date/SignOff: Reinspect?:
Trench/UG: '/, is - I(.-
Special Instructions
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Special Instructions: Z /�1 _��„ , 1�: /, a �'/��� S ; /(ij, 2�i ;'k _ r� SJLL� /,/llQti_�y�>f fad
Final: —7-1O -1i �7py\
SRE Called In: 25647150 G
Signature:
Fee Type:: Amount: DatePaid
Electrical $260.00 4/6/2018 0:00:00 6297
212 Main Street,Phone(413)587-1244,Fax(413)587-1272-Inspector of Wires -Roger Malo
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5 POMEROY TER EP-2018-0780
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Map: 32A
Lot: 186 ELECTRICAL PERMIT
Pennit: Electrical
Category: WIRE 6 UNIT APARTMENT BUILDING
Permit# Electrical
PERMISSION IS HEREBY GRANTED TO:
Project# JS-2018-000777
Est.Cost: Contractor: License:
Fee: $450.00 PIONEER VALLEY ELECTRIC MASTER ELECTRICIAN 14301A
Owner: WINTERBERRY LLC
Applicant: PIONEER VALLEY ELECTRIC
AT. 5 POMEROY TER
Applicant Address Phone Insurance
PO BOX 178 (413) 532-6098 C- Liability, ODNA051912
FEEDING HILLS MA01030 ISSUED ON:4/6/2018 0:00:00
TO PERFORM THE FOLLOWING WORK:
WIRE 6 UNIT APARTMENT BUILDING
Call In Date: Date Requested Inspection Date/SignOff: Reinspect?:
Trench/UG:
Special Instructions
X
Rough c� - �� �� -au/� 1Ba CV S{arr�rti> P-M
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Special Instructions:
Final: -7'
SRE Called In•
Signature:
Fee Type:: Amount: DatePaid
Electrical $450.00 4/6/2018 0:00:00 6297
212 Main Street,Phone(413)587-1244,Fax(413)587-1272-Inspector of Wires -Roger Malo
9 POMEROY TER - UNIT 1 & 2 EP-2018-0782
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Map: 32A
Lot: 186 ELECTRICAL PERMIT
Permit: Electrical
Category: COMPLETE WIRING OF NEWLY CONSTRUCTED 2 FAMILY DWELLING
Permit# Electrical
PERMISSION IS HEREBY GRANTED TO:
Project# JS-2018-000780
Est.Cost: Contractor: License:
Fee: $270.00 PIONEER VALLEY ELECTRIC Journeyman Electrician 36945E
Owner: WINTERBERRY LLC
Applicant: PIONEER VALLEY ELECTRIC
AT. 9 POMEROY TER - UNIT 1 & 2
Applicant Address Phone Insurance
PO BOX 178 (413) 532-6098 C- Liability, ODNA051912
FEEDING HILLS MA01030 ISSUED ON:4/6/2018 0:00:00
TO PERFORM THE FOLLOWING WORK:
COMPLETE WIRING OF NEWLY CONSTRUCTED 2 FAMILY DWELLING
Call In Date: Date Requested Inspection Date/SienOff: Reinspect?:
Trench/UG:
Special Instructions
X J/
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x
Special Instructions:
Final: 17-10 _/q Q f'
SRE Called In: 25646712
Signature:
Fee Type:: Amount: DatePaid
Electrical $270.00 4/6/2018 0:00:00 6297
212 Main Street,Phone(413)587-1244,Fax(413)587-1272-Inspector of Wires -Roger Malo
5 POMEROY TER EP-2018-1018
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Map: 32A
Lot: 186 ELECTRICAL PERMIT
Permit: Electrical
Category: INSTALL CONVENTIONAL FIRE ALARM SYSTEM IN COMMON AREAS OF MULTI APARTMENT BUILDING
Permit# Electrical
PERMISSION IS HEREBY GRANTED TO:
Project# JS-2018-000777
Est.Cost: Contractor: License:
Fee: $180.00 INDUSTRIAL TECHNICAL SERVICES INC Electrician 16760
Owner: WINTERBERRY LLC
Applicant. INDUSTRIAL TECHNICAL SERVICES INC
AT.- 5 POMEROY TER
Applicant Address Phone Insurance
975 NORTH RD (413) 568-1427 C-
WESTFIELD MA01085 ISSUED ON:6/21/2018 0:00:00
TO PERFORM THE FOLLOWING WORK:
INSTALL CONVENTIONAL FIRE ALARM SYSTEM IN COMMON AREAS OF MULTI APARTMENT
BUILDING
Call In Date: Date Requested Inspection Date/SignOff: Reinspect?:
Trench/UG:
Special Instructions
X
Rough _ 8 -/Y py VN
X
Special Instructions:
Final: -7 /U " 2Ft^
SRE Called In:
Signature:
Fee Type:: Amount: DatePaid
Electrical $180.00 6/21/2018 0:00:00 3633
212 Main Street,Phone(413)587-1244,Fax(413)587-1272-Inspector of Wires -Roger Malo
7
5 POMEROY TER EP-2018-0736
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Map: 32A
Lot: 186 ELECTRICAL PERMIT
Permit: Electrical
Category: WIRING FOR TEMP ELECTRICAL SERVICE
Permit# Electrical
PERMISSION IS HEREBY GRANTED TO:
Project# JS-2018-000777
Est.Cost: Contractor: License:
Fee: $60.00 PIONEER VALLEY ELECTRIC MASTER ELECTRICIAN 14301A
Owner: WINTERBERRY LLC
Applicant. PIONEER VALLEY ELECTRIC
AT. 5 POMEROY TER
Applicant Address Phone Insurance
PO BOX 178 (413) 532-6098 C- Liability, ODNA051912
FEEDING HILLS MA01030 ISSUED ON:3/22/2018 0:00:00
TO PERFORM THE FOLLOWING WORK:
WIRING FOR TEMP ELECTRICAL SERVICE
Call In Date: Date Requested Inspection Date/SignOff: Reinspect?:
Trench/UG:
Special Instructions
X
Rough
x
Special Instructions:
Final:
SRE Called In: 25866503 c/_ /a '/S
Signature:
Fee Type:: Amount: DatePaid
Electrical $60.00 3/22/2018 0:00:00 6282
212 Main Street,Phone(413)587-1244,Fax(413)587-1272-Inspector of Wires -Roger Malo
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBINt j1NORK
- CITY MA DATE[ 3 '_Z 2, PERMIT#
JOBSITE ADDRESS OWNER'S NAME
OWNER ADDRESS TEL
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TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONALE] RESIDENTIAL
PRINT
CLEARLY NEW:&jj' RENOVATION:Q REPLACEMENT:® PLANS SUBMITTED: YES ZNOQ
FIXTURES 7 FLOOR— BSM 1 2 3 1 4 5 6 7 S s 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
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DRINKING FOUNTAIN
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TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liabilitv insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO Q
IF YOU CHECKED YES,PLEASE NWCATE THE TYPE Oi COVERAGE BY CHECK?:G THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY X OTHER TYPE OF INDEMNITY Q BOND Q
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 Q AGENT Q
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 compliance with all erti e t pr ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. J/'/II
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POWNER ADDRESS TELTFAX
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PRINT
CLEARLY NEW: RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES E�rNO❑
FIXTURES 7 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 GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM -
DISHWASHER
DRINKING FOUNTAIN -
FOOD DISPOSER
FLOOR/AREA DRAIN 2111
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
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 CK OTHER TYPE OF INDEMNITY 0 BOND 0
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 Q 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 complianceyvith all Pertinent vision f the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. //J
PLUMBER'S NAME mA_R_'� Sirr-i L IANC
LICENSE# r al SIGNATURE
MPN JP[ CORPORATION ES PARTNERSHIP# LLC[I#
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CITY _(, ��' ._J3.1!9 J ... . ._ STATE FL'-ice..t ZIP Of� TEL �//�" S.�I' 000
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POWNER ADDRESS 1, TEL�� FAX
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FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 1 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OlUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK b ri Plar r' 8 G, Ins�e ions
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO E-]
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE M CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY X OTHER TYPE OF INDEMNITY ❑ BOND [Q
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 �]
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 est of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in comp' will P�grtina pr ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME MA R. < Sic' L i AN�? LICENSE# r a [ SIGNATURE
MP;K JP[] CORPORATION[# PARTNERSHIP# LLCQ#
COMPANY NAME Sicil-iA V0 ,F ADDRESS a tj _coq r#Je ®rid SCA)
CITY (��� __. 1A.('� STATE ZIP �/� TEL .�//Y'"Jr�` - fee
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING,.INORK
- CITY MA DATE
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JOBSITE ADDRESS }i OWNER'S NAME �,/ , meati L L C
POWNER ADDRESS TEL =FAX
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PRINT ^
CLEARLY NEW:El--'RENOVATION:Ej REPLACEMENT:F—.1 PLANS SUBMITTED: YES[✓J/NOO
FIXTURES 7 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 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
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK
TOILET
URINAL IVI
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liabilitv insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO
IF YOU CHECKED YES,PLEASE flWCAT E THE TYPE OF COVERAGE GY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY X OTHER TYPE OF INDEMNITY [] BOND 0
OWNER'S INSURANCE WAIVER:1 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 F-1 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 b t of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compli with ill Pp�tinen rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / v/r
PLUMBER'S NAME rnA F._ Sic# L 49N
LICENSE# SIGNATURE
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CITY MA DATE . Z Z-(f PERMIT#
JDBSITE ADDRESS OnrC/d cl OWNER'S NAME
POWNER ADDRESS TELT— FAX I
TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL RESIDENTIAL Eil
PRINT
CLEARLY NEW:af RENOVATION: --] REPLACEMENT:E] PLANS SUBMITTED: YES[J"NOQ
FIXTURES 7 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 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 ` n
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES AFATHU
WATER PIPING
OTHER
INSURANCE COVERAGE:
have a current liabili 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 DY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY X 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 Q 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 f y k Wedge
and that all plumbing work and installations performed under the permit issued for this application will be in complian �'h rtirRt pro i on the
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Massachusetts State Plumbing Code and Chapter 142 of the General Laws. y/
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBIN/WORK
CITY c MA DATE 3 ZZ"! PERMIT#
JOBSITE ADDRESSDnp �o c�R. 2 hr OWNER'S NAME
POWNER ADDRESS 1 . J TEL FAX -
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL Q RESIDENTIAL
PRINT
CLEARLY NEW:d RENOVATION:Ej REPLACEMENT:0 PLANS SUBMITTED: YES(9(NO❑
FIXTURES 1 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 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 an I
LAVATORY
ROOF DRAIN fir —L
SHOWER STALL
SERVICE/MOP SINK
TOILET _ _ A NorthAttir)ton A Ot
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liabilibLinsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO
IF YOU CHECKED YES,PLEASE lNDiCATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE E BOX BELOW
LIABILITY INSURANCE POLICY X OTHER TYPE OF INDEMNITY 0 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 F-1 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 b of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complia with II Perti ent r vi on of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 71
PLUMBER'S NAME MAF. -� . Sjci L49"0 LICENSE# day IGNATURE
MPj&I JP[❑ CORPORATIONPARTNERSHIPEJ# LLCQ#
COMPANY NAME .5iLil-i AN0 ADDRESS i 0FN _e� rP e )040 A�
CITY�(, j('/� J —��STATE�L J ZIP _ .L�/C?`f• TEL
FAX CELL EMAIL OG 6>0M
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