HomeMy WebLinkAboutBLDP-18-006723 Men alell d/JA
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
=Li= CITY 'int\A^ot r
AL MA DATE 6 m i 8 PERMIT# � ` 47;4
JOBSITE ADDRESS '1 '1 S)OSori�Si;,--rks \Uh Q OWNER'S NAME �Gc1\'cr. v`
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION$ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
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/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER ( 41K 9 7)18
DRINKING FOUNTAIN p1
FOOD DISPOSER
FLOOR!AREA DRAIN 6UtLDING DEenatn
Rv' _
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY •
ROOF DRAIN
SHOWER STALL 2
SERVICE I MOP SINK
TOILET — 9 JOU
URINAL Lia
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES it
V
WATER PIPING _
OTHER •
iINSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YEW NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY 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
I 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
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 Pertinent pro ' ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME ?LI v.cAcA SN\0 Q LICENSE# .133'V7. SIGNAT E
MI2'0. JP 0 ( CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME 11'\V JO j.,' . +e c` \---0�1)a ADDRESS 8 1�o' J N^a-S L1/4/
CITY ,crr,'-x" rk"- STATE WA ZIP 0a5-6'3 TEL ra8 - fo—`—fa/,G
FAX CELL EMAIL 19ket� '}'R R 9 S mc,( ton
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
frz-e THIS APPLICATION SERVES AS THE PERMIT 0 0 7-0/7/'i
n FEE: $ PERMIT# (//�/)
Li v PLAN REVIEW NOTES (�J
5 ar NO 7)-(t-4- F/1 f ic orr i
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