HomeMy WebLinkAboutBLDP-18-006223 •
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MASSACHUSETTS� UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
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aMA DATE r/ / S PERMIT# %O/re/F-4,
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nJOBSITE ADDRESS / 6 1 Chink- C .r OWNER'S NAME avai- A/onv,
POWNER ADDRESS TEL iFAAXX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL LLQ
PRINT
CLEARLY NEW:V RENOVATION: ❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
FIXTURES 1 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/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM •
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER / •
DRINKING FOUNTAIN _
FOOD DISPOSER R F G r I 1,11;7:
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
_ KITCHEN SINK MAY )4 2118
LAVATORY
3-, a. ' i
ROOF DRAIN BUipi a„rl -r r
SHOWER STALL _ / a y _ off_...:_:_l
SERVICE I MOP SINK
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TOILET )-- '1 '
URINAL "S
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. YES NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THEN E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POUCY ( OTHER TYPEOF 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
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Massachusetts General Laws,and that my signature on this permit application waives this requirement.
T - CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
VI I hereby certify that all of the details and information I have submitted or entered regarding this application are trued accurate to the •- t• my knowledge
and that al plumbing work and Installations performed under the permit issued for this application will be In c•.m•.�FlTa•with tall Pe ' en„t ision of e
Massachusetts State Plu ing Code and C apter 1442 of the General Laws. '
•
PLUMBER'S NAME
a yr of /10 vim - LICENSE# .13 3 0 c / / SIGNATURE
MP ❑ JP (� / / CORPORATION❑# PARTNERSHIP❑.# LIC❑# /� /
COMPA//N//Y NAME l/ CL-A f244 ,�,,�,, ^^ ADDRESS (0( QYte. <-4,,A.,, /L••y
CITY ttarwr�c‘ STATE/ZIA- ZIP U--//* `/ r //// E
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FAX CELL EMAIL •C:/a✓fc/I/oV(M G e._ Cnt... F
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
/J ,^L -61f7,4 THIS APPLICATION SERVES AS THE PERMIT 0 0
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PLAN REVIEW NOTES �/
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