HomeMy WebLinkAboutBLDP-18-5710 6./N/1/ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
3l+/ CITY \/ MA DATE tft/Se-. PERMIT# P7't' °J67/O
JOBSITEADDRESS '/0 CP,,`61 q- re_A-. OWNER'S NAME AKA Ci!.fzicS t3.. (-01/4-
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENT1A!.
PRINT
CLEARLY NEWt, RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES Pa. NO 0
FIXTURES 7 FLOOR-r BSM 1 2 3 4 5 6 7 B 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 • r
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN C' E -CP r r r
INTERCEPTOR(INTERIOR) -----••- - !
KITCHEN SINK - ( I
j LAVATORY ,c-• q - m7 n 9 L
ROOF DRAIN
SHOWER STALL - • .
SERVICE I MOP SINK iv I
I TOILET - S j
URINAL
WASHING MACHINE CONNECTION -- t 1 -
WATER HEATER ALL TYPES a:
WATER PIPING I
OTHER
6n-rSY6 SN<:torze)_ I
6.142-Sba14-
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES( . NO 0
IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
1 LIABILITY INSURANCE POUCY kE4r-- 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
1 Massachusetts General Laws,and that my signature on this permit ap?fication waives this requirement.
T CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
1-1.1 I hereby certify that all of the details and information I have submitted or entered regarding this application .-- 's n. - ete i. ,- best of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be In.omp - c=. ,• trey! ant provision of the
Massachusetts State Plumbing Codeand Chapter 142 of the General Laws. ` 1 NW-
PLUMBER'S NAME %s3 C't` $ '
LICENSE / 'TIP' RE
MP �4 JP 0 CORPORATION[gilt SAKCs7 PARTNERSHIP❑.# LLC❑,#
COMPANY NAME 1 { 43CQ�RY� ktact 1.`a)(_ ADDRESS 4 Z 1>,tc�C4 u s3&cCC- AW
CITY 2PC-uDSA�_ STATE V 41/4- ZIP O D-Col. \ TEL 774 • fa-it SS'?
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FAX CELL EMAIL `�A64 `. . ykl,1/4,4,' QC ,k1a
. GRF) 3p
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
-k cr%P -M Yes No
WJ THIS APPLICATION SERVES A5 THE PERMIT ❑ ❑ /) , Jr#
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FEE: $ PERMIT A 0' N ') C/ ,n- 46(2
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