HomeMy WebLinkAboutBLDP-19-000405 •
MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TOPPERFORM PLUMBING WORK
,_--, � (j1 I \( \� 7J��/�) p PERMIT#/3&OP� -000 9°6
- CITY p,ST IUiYV1Ov MA DATE
JOBSITE ADDRESS S3 We niAt rf /a% 4 OWNER'S NAME zRetr% t ,2e a h I
n
P OWNER ADDRESS 4'"o glut. 04Jrilt TELS08-3e7'/fit FAX__ _
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 11,----
PRINT
CLEARLY NEW:0 RENOVATION: V REPLACEMENT:0' PLANS SUBMITTED: YES 0 NO p.--•--.
FIXTURES 7 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB i
CROSS CONNECTION DEVICE •
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/01L/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 /
\I LAVATORY
OP ROOF DRAIN i. ^ C E ` V E-B
SHOWER STALL
SERVICE 1 MOP SINK I //��, .q�
� ^I TOILET _ I .,111 ,911&1p 11.
4URINAL I
, WASHING MACHINE CONNECTION ----DI
IVIWATER HEATER ALL TYPES uvu',ni ,ir. nrn , .� Vi
WATER PIPING
OTHER
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J�S
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.14L YES p' N0 0
r
IF YDU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
4'-
So LIABILITY INSURANCE POLICY V OTHERTYPEOF 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
s
Massachus Ge ws,ay ignature on this permit application waives this requirement
c. CHECK ONE ONLY: OWNER GENT 0
SIGNATURE OF OWNER OR AGENT
�`I 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 Perlin sion of the
Massachusetts State Plumbing Code and)Chapter 142 of the General Laws.
PLUMBER'S NAME JCpl1I LICENSE#PUG3fY/4j SIGNATURET
• MP JP 0 C n 1 CORPORATION 0# PARTNERSHIP Q# LLC 054;-21y3 Y26
COMPANY NAME( J R 91 U1'ti b(/�i ADDRESS to Bei 2P2
CITY f ott4t, fey- J STATE Atil ZIP 00eca TEL 3'082(//•3793
FAX CELL 5C.roc, EMAIL 6 P#
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ D ti6 ,,02 S A- //UJ
FEE: $ PERMIT It Cf) /10/ firen ll-eca pcit
PLAN REVIEW NOTESF/V, I7}-e
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