HomeMy WebLinkAboutBLDP-19-002292 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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--e �-4 MA DATE lift t ( r PERMR# P-/9-00
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JOBSITE ADDRESS /D 9 [_/1 rqh L.J OWNER'S NAME L-ea
OWNER ADDRESS C/ TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO 0
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/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM 1
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
-
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER _
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch-142. YES 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE ONLY: OWNER 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT
Li I hereby certify that all of the details and Information I have submitted or entered regarding this application are tru- -n• - curate to the be •f my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be In come— th all P-- 5• • •vis'n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME D o--;d h4„.2 LICENSE# 0 C SI NATURE
MP❑ JP �J CORPORATION❑# PARTNERSHIP
0# LLC❑# �/J
COMPAME „Tao c.-0( /2-�l� ADDRESS I0/l7 Ov-u� /�ti os 72
CITY a 2 ///(¢!— STATE ZIP Od aci r// TEL
ten/FAX CELL EMAIL V 4 to h/ov4 icj V'/Sta.//
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ROUGH PLUMBING INSPECTION NOTES )3ELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
pcmi-c. A-6FEE: $ PERMIT# ‘81 - /14?
PLAN REVIEW NOTES G !!