HomeMy WebLinkAboutBLDP-19-002171 •
.% MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY 12.(0!1! Tt' MA DATE 0—//"/ r PERMIT# AN'tV&a[r.
JOBSITE ADDRESS/O/ Cts/pO/b/6 6?Cyj/II G12 OWNERS NAME iiii_CcAJIL '
POWNER ADDRESS TEL EN ,,FAX/
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 711.-------
PRINT
CLEARLY NEW:0 RENOVATION: REPLACEMENT:E] PLANS SUBMITTED: YES 0 NO❑
FIXTURES 1 FLOOR-, BSM 1 2 3 4 5 6 7 B _ 9 10 11 12 13 14
BATHTUB Ry -._.,
CROSS CONNECTION DEVICE C° 11,_
0
DEDICATED SPECIAL WASTE SYSTEM '
DEDICATED GAS/OIL/SAND SYSTEM EDDEDICATED GREASE SYSTEMDEDICATED GRAY WATER SYSTEM UILD NG pNfi
DEDICATED WATER RECYCLE SYSTEM 1—=_—
DISHWASHER - _
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
__ KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK -
i TOILET
URINAL
i WASHING MACHINE CONNECTION
I WATER HEATER ALL TYPES
WATER PIPING
{ OTHER
I "
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES £ NO 0
IF YOU CHECKED YES,PLEASE INDICATE THETYE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY OTHER TYPE OF INDEMNITY ❑vy
BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
1 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 •- and ay-"te to the best of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be I 'ante o j. all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ' / J#
PLUMBER'S NAME LICENSE#8T.09 . SIGNATURE
MP 0" JP 0 CORPORATION❑# PARTNERSHIP Q# LLC❑#
COMPANY NAME ADDRESS ZX- ,f77
CITY GV -" Y" )C STATE Pio ZIP 0ZA VS TELspf-IL 7-in 3/
FAX CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ 0
FEE: $ PERMIT ti
PLAN REVIEW NOTES /J J //8
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