HomeMy WebLinkAboutBLDP-17-004883 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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%WA? CITY orior",, +er7 MA DATE 749-71/7 PERMIT# "7-1 7-471'7.90-/
JOBSITE ADDRESS 2 Z G/'LC✓1/Arid at/C OWNER'S NAME trr d M/i'A)Gi,.Jk
OWNER ADDRESS w TEL 775 V7J7 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIALO
PRINT
CLEARLY NEW NEW:Q3 RENOVATION:0 • REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
FIXTURES 7 FLOOR-4 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/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM •
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER _ Rg c E f F 4,x
FLOOR/AREA DRAIN __•_1 I
INTERCEPTOR(INTERIOR)
KITCHEN SINK I Mai? 31
LAVATORY • 4
ROOF DRAIN
. SHOWER STALL mill y�C�f� > 4 I
, je
SERVICE/MOP SINK
• TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
af?titrp >0
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY 0 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
j Massachusetts General Laws,and that my signature on this permit apQlication waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
L11 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 Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# Ce2/eP SIGNATURE
MP 0 ,11> Ps CORPORATION 0# PARTNERSHIP❑.# LLC 0#
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COMPANY NAME 014 D /r,,64.e/n.- L ADDRESS 0202 &ceoi lA.t�I Ctrr,/e
CITY .Glo.y„o ar,--r STATE 44 ZIP 672C7-5- TEL 779994/7.-97
FAX CELL EMAILevea. M,;Lc 1A_ rLi dyoiln .Cr",
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ 0
FEE: $ PERMIT# y ;/ ., 6
PLAN REVIEW NOTES U(/�-