HomeMy WebLinkAboutBLDP-19-002455 / A
t MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
_e CTY//14//VO(LP 4 MA DATE / i PERMIT# "/7"004'7
JOB SITE ADDRESS .. _s Ii ar C/ OWNER'S NAMr___CaY_______
POWNER ADDRESS 4 G TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT ./
CLEARLY NEW:0 RENOVATION:�J REPLACEMENT:❑ 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
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR) E ' V F .1
KITCHEN SINK
._\
j LAVATORY -
ROOF DRAIN2,4 t)i(
SHOWER STALL 1
•
SERVICE/MOP SINK BUuni Nr7 7EPAiiTME T
( TOILET eY,,,,,-__
URINAL
• WASHING MACHINE CONNECTION /'
WATER HEATER ALL TYPES /
WATER PIPING 1 7.
OTHER,Sb,v/"ro,flffC%/Q a ,/
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 1 N0 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY it 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.
'Z CHECK ONE ONLY: OWNER 0 AGENT 0
' SIGNATURE OF OWNER OR AGENT
LLI I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and accurate to the be fknowledge
and that all plumbing work and Installations performed under the permit issued for this application will be I •Ilance with all Pertine • •vi1� of the
Massachusetts State PlumbingLCode and Chapter 2 of the General Laws. - /
PLUMBERS NAMES7 AA- Ga/ LICENSE s— ��RE
v lao /
MP 27 JP 0 /� / CORPORATION 0# PARTNERSHIP❑.# LLC3 Vis.
COMPANY
�NAME R/J•La/-eK�t (!/)li//le' ADORES i _ A - C r/ I
CITY h/DT//I/c ST TE ZIP _S TEL hof y3, os3o •
L
FAX CELL 5ofl37/751 EMAIL 9o2QCn/7)%S�, /2 C7
GI6*371 '4SO (.10//-01
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes Na /�
THIS APPLICATION SERVES AS THE PERMIT 1:1❑ //(yr/O/"(
FEE: $ PERMIT# / 2`/]T LL/3/�
PLAN REVIEW NOTES
y.