BLDP-18-006807 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
j-:7 CITY YAdManl{ MA DATE 5I31 f 1 P. PERMIT#11/.841.9-00a27
JOBSITE ADDRESS g 0.16kIET KO OWNER'S NAME &CI M o >J
OWNER ADDRESS TEL 5a8-S -1111 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT •
CLEARLY NEW:V RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO''
FIXTURES 1 FLOOR—I BSM 1 2 3 4 5 6 7 6 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM _
DEDICATED GAS/OILISAND 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 - L.
ROOF DRAIN y
SHOWER STALL 3 1 1!
SERVICE/MOP SINK
TOILETA
URINAL BUILUINC •r I M t�"A's
• 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 r. NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILrfYINSURANCE POLICY IJ 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 0 AGENT 0
• SIGNATURE OF OWNER OR AGENT
LU 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.
PLUMBER'S NAME NIGRA— (L Data `IA's LICENSE# 17 443. SIGNATURE
MP Q' JP❑ CORPORATION❑# PARTNERSHIP Q# LLC❑#
COMPANY NAME CAIIEEc.M67 PLoMhy.l& < 14c4l'i(, ADDRESS 135. CA4mdti1 SMktcr tt0 .
CITY S . `(Mm.cn.1T4 STATE MA- ZIP 02.4,a-u( 'TEL 111- 1” - 1844
FAX CELL EMAIL ch,PEAh to WrMtnMG @ `Uslid
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
Plek Pa
e� � a FEE: $ PERMIT# I9Wfr - P� -
djcr PLAN REVIEW NOTES
Or fr (...A
X61
•