HomeMy WebLinkAboutBLDP-19-000849 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
---moi_ CITY \Nest 40MA DATE g'-'15-24911(15-2911( PERMIT# /z/9-o6O //JJ
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JOBSITEADDRESS 5IG'tY�k f� etI OWNER'S NAME'c i)'bm^¢ 064-74-
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POWNER ADDRESS CA-ale— TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7 FLOOR—' BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE •
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM • •
DEDICATED WATER RECYCLE SYSTEM
•
DISHWASHER •
DRINKING FOUNTAIN
FOOD DISPOSER •
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) _,._ . .„ __
KITCHEN SINK F' r' C r x ;
LAVATORY I
ROOF DRAIN
SHOWER STALL f 29 U_3
• SERVICE I MOP SINK ;
I TOILET
URINAL th1 1 L I
WASHING MACHINE CONNECTION
WATER HEATS ALL TYPES
• WATER PIPING
OTHER
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YESI' NO 0
IF YDU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY, OTHER TYPEOF 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
144 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!Derma issued for this application will be N compliance with all P 'nest provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME 5co._, Ftetn Zia, LICENSE# SB'22 . SIGNATURE
MP tt JP❑ CORPORATION❑# PARTNERSHIP Q# LLC 0#
COMPANY NAME gaol ratan P ADDRESS ea 03)c IoW
CITY 0 erste. c U'.. STATE m ij'" ZIP 026 TELcncr-23t-v2S4
FAX CELL EMAIL `r anrk ., ?✓arbors®g4�-Le,„t
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No /
THIS APPLICATION SERVES AS THE PERMIT D 0 )9..c /91
9 J C/ `—
FEE: $ PERMIT It
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PLAN REVIEW NOTES J }U�/G✓