BLDP-18-006552 J
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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=_I -- CITY telt-cc %tAarvlduTR MA DATE fi/C1 1Q PERMIT# e n-1/27-00‘ 7,
JOBSITEADDRESS a LY(,n1ET Lb OWNER'S NAME [;ON MO2_I34
OWNER ADDRESS TEL 5;38-5tc-1412 Er TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL Lr
PRINT _
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:pJ PLANS SUBMITTED: YES 0 NO Er
FIXTURES 1 FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 1
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM •
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER I •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
1•
i ROOF DRAIN
SHOWER STALL •
_
SERVICE/MOP SINK
TOILET It MAY 17 2018
URINAWASHING
WASHING MACHINE CONNECTION
D,
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 VNO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY 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
i Massachusetts General Laws,and that my signature on this permit ap?lication waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
1-11 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 Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME 1411(Atka 9-- 't�aaow LICENSE# tc4 -k%. SIGNAT
MP Er JP❑ CORPORATION 0# PARTNERSHIP 0# LLC❑#
COMPANY NAME chat tOF N‘stbAntAlL, ` V.VOY \*1& ADDRESS 1°f 04171.1)4 SM/trt,L
CITY 4 . krtMctl7N STATE MA ZIP 616C64 TEL 114 ictl -189'4
FAX CELL EMAIL CAQaa1/40citvmh Wb(`UM00. Co nil
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
l ',�1 THIS APPLICATION SERVES AS THE PERMIT El 1:1f'�J/ f 01114 4 FEE: $ PERMIT# "`� ✓� ' `7
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PLAN REVIEW NOTES
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