HomeMy WebLinkAboutBLDP-19-000788 MASSACHUSETTS •
yTUNIFORM APPLICATION FORA -E- ITTTOOJPERFORM PLUMBING WORK
CITY y/f/2J✓ 00774 MA DATE i 173 PERMIT#'I A��`00O
JOBSIrE ADDRESS / �Com✓"/ iii&INNER'S NAME 'RG� '
P OWNER ADDRESS SStI /"I a TEL FAX
LFA
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCA NAL 0 RESIDENTIAL Ly'
PRINT
CLEARLY NEW 0 RENOVATION:0 REPLACEME • PLANS SUBMITTED: YES 0 NO 2"
FIXTURES 7 FLOOR-4 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/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 � I y;, - r4., C- Y 'J fit- �} _
LAVATORY f _T__._ —"'—H
ROOF DRAIN
SHOWER STALL ;I • - •
SERVICE 1 MOP SINK
TOILET epiflikitILE : N .1T -
WASHING
URINAL _�
WASMACHINE CONNECTION
WATER HEATER ALL TYPES q
WATER PIPING /
OTHER •!
T
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial e • lent Which meets the requirements of MGL Ch.142 NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYP VERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POLICY OTHERTYPEOF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAVER: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 apQlication waives this requirement
` CHECK ONE ONLY: OWNER 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT
:1:I I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and ac ate 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 wit rtlnent provision of the
Massachusetts State Plum ' g Code and Chapter 142 of the General Laws.
PLUMBER'S N 1). LICENSE# /•`j W/.6 SIGNATURE
MP JP CORPORATION 0# PARTNERSHIP 0.4i LLC❑#
COMPANYNAM in e ti
1 / ■ ADDRESS 2C71- �T' b"' leer'
CITY y� tITM STATE W44 ZIP c226 73 TE s-/
FAX CELL EMAIL Z.-leti
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BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
ROUGH PLUMBING INSPECTION NOTES
Yes No
4 I 0 n'� THIS APPLICATION SERVES AS THE PERMIT 0 ❑ pey t I �7
/- rA/70" FEE: $ PERMITS L / 7- g7,9-7//r
PLAN REYJEW NOTES