HomeMy WebLinkAboutBLDP-18-002650 •
MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
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CITY rarehittA MA DATE J/Q/I7 PERMfT#1444/1171(47/5/63
JOB SITE ADDRESS /4;4 An;7S'/4-,gear Nd' OWNER'S NAME Ttf CO4/a r dS
POWNER ADDRESS TEL.S 4f- 77F7 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL[r
PRINT
CLEARLY NEW:0 RENOVATION:[W REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
FIXTURES 7 FLOOR-.. 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/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER / • -
DRINKING FOUNTAIN _
FOOD DISPOSER
FLOOR/AREA DRAIN + '
INTERCEPTOR(INTERIOR) i
KITCHEN SINK / ! taYQ [U I ;
LAVATORY •
ROOF DRAIN �Ptirtl
y1 i
I SHOWER STALL f` [I6/ri
SERVICE 1 MOP SINK
TOILET Z '
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE: Ere -NO
t i I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0
fit IF YOU CHECKED YES,PLEASE INDICATES THETYPEOF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILTfYINSURANCE POLICY r� OTHER TYPE OF INDEMNITY ❑ BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
4-1 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 becn--s-p,)mpliannce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. -0//
PLUMBER'S NAME 'green Cecc l2. LICENSE# 2.3/76. SIGNATURE
MP D JP a / CORPORATIONf ❑# PARTNERSHIP Q# LLC❑#
COMPANY NAMEIDe ice>✓(P/uMb��fy7fG/yil/Uifv, ADDRESS 70 kW y
CITY mr1'/r� A*4 STATE` 4. ZIP/33 9 4 y? TEL5d5- 0—00/2
FAX CELL EMAIL
02ik 160
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
` Yes No
FM-794
49 a7 i /J ' THIS APPLICATION SERVES AS THE PERMIT 0 0 fPZAfC-
/J/��/� 77/7 /C FEE: $ PERMITft , " p &
PLAN REVIEW NOTES Z'gyL"i