HomeMy WebLinkAboutBLDP-17-004464 D P /6-60/33 3 5/c//'+ 0 F/J'_) n/y= 4,06-71t MA-tsr/
MASSACHUSETTS UNIFORM APPLICATION FOR-A PERMIT TO PERFORM PLUMBING WORK
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, / y{a<l2"7nri��r MA DATE 3 — -I/ PERMIT#/ fr�L7-00 d
JOBSITE ADDRESS re- ",..741.A., 4i.4y OWNER'S NAME/i4/2I9c f.7'I-e2rhT
POWNER ADDRESS 1Z --v4/i L/.v 4.- 5Z,y TEL FAX
TYPE OR • OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAII0—'
PRINT
CLEARLY NEW: ll RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE _
DEDICATED SPECIAL WASTE SYSTEM \
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM _ _
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER / _ •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK / L� C . I V b i
LAVATORY a • I
r�
ROOF DRAIN
SHOWER STALL I. MAR 30 2311
SERVICE I MOP SINK '
TOILET a nUIL 1W1 n 41
URINALt - i----�3
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. YE NO 0
IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POUCY ®- 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 i y
j Massachusetts General Laws,and that my signature on this permit application waives this requirement.
j CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
L 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 Pe Inent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# /J07 y SL•
SIGTIATURE e
MP❑ JP CORPORATION❑# PARTNERSHIP 0# LLC❑#
COMPANYNAMEAY/C4n L E .rp4,¢7oe ADDRESS as pROSPec/ -I ./
CITY tit yAR• STATE ,W11. ZIP 02493 TEL Slog' 222-0/fd'
FAX 4.4-4.,-I CELLS/t- „CZ Z.-(Wei EMAIL /ow f
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
l /� /2_6 c�/a THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ `/ , U/L�
FEE: $ PERMIT St r t1`�`Z lei I
PLAN REVIEW NOTES
01/47