HomeMy WebLinkAboutBLDP-18-005917 ' l °:- 1
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMITTOPERFORM PLUMBING WORK
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CITY �� � MA DATE ����'�� d PERMIT#sekDif'e0� 17
JOBSITE ADDRESS 35 U I k/oo KC OWNER'S NAME (3�a r i a-
P OWNER ADDRESS ✓A 'N`e•-...-- TEL FAX
•
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL RESIDENTIAL 5--
PRINT
CLEARLY NEW:0 RENOVATION:eh REPLACEMENT:0 PLANS SUBMITTED: YESS—NO 0
FIXTURES 1 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 ----___—_IIMFA�111111DED _-_
DEDICATEDIll
(DED
D GREASE SYSTEM 11/11111gallil
D GAS/OIL/SAND SYSTEM
GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRIN
FOUNTAIN 1111 II I
FOOD
POSER
.O AREA DRAIN
INTERCEPTOR _ ..
I
2 •
I ROOF DRAIN
APR zq 'uib
i URINALMIS�WFAI -- Tom---- r ,i.
1 WASHING MACHINE CONNECTION _
i WATER HEATER ALL TYPES
1 WATER PIPING
I OTHER
1
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YE'NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE DE COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 1 ,-- OTHERTYPEOF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I ant 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 application waives this requirement
2 CHECK ONE ONLY: OWNER 0 AGENT 0
3.--
SIGNATURE OF OWNER OR AGENT
LiI 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 oomph with all Pertinent ravision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME J`mQo rn o V� 1 LICENSE# ` tl�C\ . SIGNATURE
MP JP 0 CORPORATION 0 it PARTNERSHIP❑.# LLC❑#
COMPANY NAME 6or4unovk- gumb(43 ADDRESS ZZ 4/ 4r4t 51--
CITY `Ieni15 STATE VV N' ZIP 0'2-63 < TEL5x5 Y_32&-4973
FAX CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES pELOW FOR OFFICE USE ONLY FINAL INSI�ECTION NOTES
Yes No
ihs / S `. THIS APPLICATION SERVES AS THE PERMIT D ❑
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A
FEE: $ PERMIT ft flQ�j ( ( /0(
1/ �� f
� / U/ PLAN REVIEW NOTES
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